Undiagnosed Non-Valvular Atrial Fibrillation and Stroke Risk: A Call to Action. PCNA Annual Symposium, April 2018

Transcription

1 Undiagnosed Non-Valvular Atrial Fibrillation and Stroke Risk: A Call to Action PCNA Annual Symposium, April 2018

2 Presenter Moderator and Speaker: Kathy Berra MSN, ANP, FAHA, FPCNA, FAAN Stanford Prevention Research Center Disclosures: None

3 Presenters Speaker: Jonathan Chrispin, MD Johns Hopkins School of Medicine Disclosures: None Speaker: Mellanie True Hills, CSP StopAfib.org Disclosures: None

4 Objectives 1. Define and discuss the magnitude of undiagnosed NVAF and its risk factors 2. Describe common signs and symptoms, screening and evaluation of patients with undiagnosed NVAF 3. Summarize stroke risks associated with NVAF and treatment strategies to prevent stroke 4. Review risk communication strategies to help patients and care givers understand risks and benefits of NVAF treatment to actively engage in shared decision making

5 Non-Valvular Afib: Definition Prevalence & Risk Factors Case Study Introduction

6 Definition - AF Atrial fibrillation (AF) is a supraventricular tachyarrhythmia characterized by uncoordinated electrical activity resulting in inefficient atrial contraction. ECG pattern: Irregularly irregular No distinct repeating P waves January CT, Wann LS, Alpert JS, et al AHA/ACC/HRS guideline for the management of patients with atrial fibrillation. J Am Coll Cardiol Dec 02;64(21):e1-76.

7 Definition - Non-Valvular AF Non-valvular AF (NVAF) occurs in the absence of rheumatic mitral stenosis, a mechanical or bioprosthetic heart valve, or mitral valve repair 4 Types: Paroxysmal: self-terminating, usually within 48 hours Persistent: lasts longer than 7 days Long-standing persistent: has lasted one year or more Permanent: presence of arrhythmia is accepted; no rhythm control is attempted

8 Prevalence and Impact of AF Most common sustained arrhythmia million people in US have AF Likely to double by 2030 to 12 million African Americans less likely than those of European descent More than 750,000 hospitalizations per year due to AF Contributes to estimated 130,000 deaths per year Medical costs about $8,700 higher per year for someone has AF US incremental cost burden of undiagnosed NVAF is $3.1 billion CDC Fact sheet 2017:

9 Prevalence of AF CDC Fact sheet 2017:

10 Prevalence of NVAF: Increases with Age in Men and Women J Am Heart Assoc Jan; 4(1): e001486

11 Challenges of AF 25% of AF is paroxysmal Episodes may be brief and undetected Subclinical AF is common: no symptoms or unaware of symptoms In approximately 20% of AF related strokes, stroke is the first clinical manifestation of AF Moran PS, Flattery MJ, Teljeur C, et al. Cochrane Database Syst Rev. 2013(4); Hannon N, Sheehan O, Kelly L, et al.. Cerebrovasc Dis. 2010;29(1):43-9.

12 Case study: Alex CC: 63 YO Hispanic M with a chief complaint of palpitations and a sense of a fast heart beat occurring sometimes when he rides his bike over the past 6 months. As of yesterday he feels it all the time. He sees you biannually for Hypertension and Hyperlipidemia.

13 Case study: Alex Past Medical History: Hypertension Hyperlipidemia Seasonal Allergies Mild OA right Hip and Knee Social History: Drinks ETOH 7-10 drinks/wk Non-smoker High School Principal Married, 2 teen age children Family History: HTN, Hyperlipidemidemia, CAD (father CABG 65) Medications: Atenolol 50 mg QD Losartan 50 mg QD Aspirin 81 mg QD Atorvastatin 40 mg QD Melatonin 2mg (HS)

14 Case study: Alex Assessment Vital Signs: BP: 138/80 HR: irregular, 70 s Wt: 180 lbs Ht: 68 in. BMI: 27.4 Kg/m2 Exam: Lungs clear bilaterally No carotid bruits No murmur No peripheral edema + DP, PT pulses, bilaterally Abdomen soft, non-tender, normal bowel sounds, no bruit Labs: 6 months ago: TC 180, TG 150, HDL 45, LDL 105 Glucose, CBC, electrolytes, LFTs wnl No recent thyroid panel Diagnostics: Stress echo 2 years ago: ECG: NSR, no ischemic changes Normal echo Appropriate HR, BP response Nml Ex Capacity: 12 METs Alex denies chest pain, shortness of breath, lightheadedness at rest or with exercise

15 What are Alex s Risk Factors for Afib? A. Age and Gender B. Hypertension and Alcohol Use C. Hyperlipidemia and Family History of CAD D. Hispanic ancestry E. None of the above

16 Risk Factors of AF Advancing age - 9% people > 65 years vs 2%<65 years, 12% years High blood pressure Accounts for ~14-22% of AF cases Obesity European ancestry Diabetes Heart failure Hyperthyroidism Chronic kidney disease Heavy alcohol use Ischemic heart disease Left Ventricular Hypertrophy Previous Cardiothoracic Surgery Sleep Apnea 4x risk of developing AF 50% AF pts have sleep apnea Lip et al; Nature Reviews Disease Primers 2, Article number: (2016)

17 Risk Factors Biological Clinical Electrical remodeling Fibrosis Hypertrophy Inflammation Oxidant stress Age Genetics Alcohol Diabetes Heart failure Hypertension Hyperthyroidism Obesity Mitral valve disease Circulation Dec 2;130(23):

18 Non-Valvular Afib: Risk Assessment Screening Diagnosis & Stroke Prevention

19 Signs and Symptoms Irregularly irregular heart rate, normal or fast Low blood pressure Dizziness or syncope Chest pain/pressure Shortness of breath, possibly cough Possibly edema TIA/Stroke Symptoms Lip et al; Nature Reviews Disease Primers 2, Article number: (2016)

20 Risk Assessment Tools Not Validated across patient populations CHARGE-AF: age, race, height, weight, blood pressure, smoking, use of antihypertensive medication, diabetes, and history of myocardial infarction and heart failure Only validated for populations in US and Western Europe HRS (Heart Rhythm Society) Interactive tool: age, gender, HTN, weight, alcohol, sleep apnea, diabetes, FH, stroke, palpitations, thyroid Morillo et al: J Geriatr Cardiol Mar; 14(3): AHA\ACC\HRS Guidelines for Afib: JACC VOL. 64, NO. 21, 2014

21 Risk Assessment Tools Framingham Afib Risk Score Age Gender Body mass index Systolic blood pressure Treatment for hypertension PR interval Significant murmur Prevalent heart failure Alex s Risk of AF 5%

22 Fitzmaurice DA, et al BMJ. 2007;335:383 Screening for NVAF 2007 randomized trial Compare targeted population-based vs. opportunistic screening Opportunistic palpation (e.g. pulse-taking) of patients aged 65+, with or without known AF risk factors = cheapest and most effective method of screening Take palpated pulse for a full minute Follow-up ECG for those with an irregular pulse Opportunistic screening was found to detect similar numbers of new cases compared with systematic screening (1.64% vs. 1.62%) Requires less resources

23 ECG Screening for NVAF US Preventive Services Task Force Review Findings: Screening with ECG can detect undiagnosed NVAF, but, no better than pulse palpation Most older adults with undiagnosed NVAF have a stroke risk above the threshold for anticoagulation Multiple treatments for AF reduce the risk of stroke & increase risk of bleeding, but no clear evidence that screening resulted in better health outcomes than detection of NVAF through usual care (opportunistic screening) or after symptoms develop AHRQ Publication No EF-1, Dec 2017

24 Screening for NVAF: AF-SCREEN People > 65 Undertreated AF Patients Primary care Specialty clinics Whom to Screen Where to Screen Opportunistic pulse then ECG Single time point, Single ECG Patient activated ECG How to Screen Special Cases Post stroke (ESUS) long term & continuous International Collaboration, White Paper; Circulation. 2017;135:

25 Is there an AF screening tool in your pocket?

26 AF Screening Methods/Tools Devices Algorithim only Examples Sensitivity (%) Specificity (%) Pulse Palpation 94 (84-97) 72 (69-75) Handheld singlelead ECGs Modified BP monitors AliveCor (Kardia) Mydiagnostick Omron HCG-801 Microlife BPA 200 Omron M6 98 (93-99) 94 (87-98) 98 (93-100) 97 (81-100) (93-99) 93 (85-97) 76 (73-79) 90 (84-94) 94 Plethysmographs Finger Probe iphone photo AF-SCREEN White Paper, Circulation. 2017;135:

27 Assessment and Tests Physical Exam Auscultate precordial wall and lungs Palpate radial artery for a full minute Retake blood pressure and heart rate 12 Lead Electrocardiogram (ECG): Class I, Level C Rate, rhythm Transthoracic echocardiogram Valvular abnormalities Chamber size/dilation, wall motion abnormalities Presence of Left Atrial Thrombi Labs: electrolytes, thyroid, renal, liver, CBC 2014 AHA\ACC\HRS Guidelines for Afib: JACC VOL. 64, NO. 21, 2014

28 Case study: Alex Next Steps 12 Lead ECG: Afib, HR Updated labs: CBC, CMP, thyroid panel WNL What next?

29 After the diagnosis of Afib is made, what next steps would be appropriate for Alex? A. Start an antiarrhythmic B. Control his heart rate C. Start him on an anticoagulant D. Nothing needs to be done because he is asymptomatic E. Refer him to an Afib specialist

30 Assessing Stroke Risk Chest Feb;137(2):263-72

31 Anticoagulation Decision-Making CHAD 2 S 2 -VASC Score = 1 HAS-BLED Score = 2

32 Lancet Aug 20;388(10046):806-17

33 Assessing Bleeding Risk No randomized clinical trial data to suggest WITHOLDING anticoagulation in AF patients based on bleeding risk score Significant overlap between stroke and bleeding risk J Am Coll Cardiol Jul 19;58(4):

34 Anticoagulation Choices for NVAF Warfarin Dabigatran Rivaroxaban Apixaban Edoxaban Class Vit K Antagonist Direct Thrombin Inhibitor Factor Xa Inhibitor Factor Xa Inhibitor Factor Xa Inhibitor Dosing and Frequency (normal renal function) Dose adjusted for INR mg BID Adjust for CrCl ml/min 20 mg QD evening meal Adjust for CrCl ml/min 5.0 or 2.5 mg BID Adjust for age, wt, renal fx 60 mg QD Adjust for CrCl ml/min Comments Numerous drug/food interactions; INR monitoring required; reversal available Interacts with inhibitors and inducers of P-gp. reversal agent available Interacts with inhibitors and inducers of CYP34A and P-gp. Interacts with inhibitors and inducers of CYP34A and P-gp Should not be used in patients with a Cr Cl >95mL/min; avoid with P-gp inducer rifampin

35 From: Oral Anticoagulant Therapy Prescription in Patients With Atrial Fibrillation Across the Spectrum of Stroke RiskInsights From the NCDR PINNACLE Registry JAMA Cardiol. 2016;1(1): doi: /jamacardio Figure Legend:

36 Further Investigations Further tests could be ordered as indicated Exercise/stress testing with or without imaging: evaluate for ischemia Holter/Event Monitoring Transesophageal Echo: identify thrombus Electrophysiology Study: clarify if wide-complex, identify predisposing arrhythmia or sites for ablation Chest X-ray: if clinical findings suggest abnormality 6 minute walk test: evaluate rate control Sleep Study 2014 AHA\ACC\HRS Guidelines for Afib: JACC VOL. 64, NO. 21, 2014

37 Case study: Alex In 3 weeks TEE Echo r/o L Atrial Thrombi Negative Study EP Study Consider Ablation for Rhythm Control Rate control is good at this point (already on Atenolol for HTN) Afib Education Shared decision making

38 NVAF: Summary Know and assess for the common risk factors for NVAF Consider and evaluate for NVAF when patients present with common signs/symptoms Palpate pulse for a full minute, complete 12 lead ECG and any other diagnostics as indicated

39 Non-Valvular Afib: Patient/Provider Communication Shared Decision Making Patient Education