Atrial Fibrillation & Acute Stroke

Transcription

1 Atrial Fibrillation & Acute Stroke

2 Acute Stroke Stroke Facts Aetiology Thrombosis Classification outcomes Time is Brain

3 Acute Stroke Over 5 million people die as a result of stroke and another 5 million are left permanently disabled worldwide every year Stroke is the 3rd biggest killer and a leading cause of severe adult disability in the UK. Every 5 minutes someone in the UK has a stroke Almost 1:4 men and 1:5 women aged 45 can expect to have a stroke if they live to 85. More than 3 times as many women die from stroke than breast cancer in the UK. For every 50 spent on cancer research and 20 on heart disease research, only 1 is spent on stroke research. What is a stroke? 2008 Stroke Association 2008

4 Acute Stroke There are around 150,000 new strokes each year. At least 300,000 people in England living with moderate to severe disabilities as a result of stroke. Stroke care costs the NHS about 2.8 billion a year in direct care costs more than the cost of treating coronary heart disease and 1.8 billion in lost productivity and disability. The annual informal care costs are around 2.4 billion. Total costs 5-7 billion National Audit Office. Dept of Health. 16th Nov 2005

5 Acute Stroke Ischemic 80% Haemorrhagic 20% Atherothromboembolic (50%) Cardioembolic (20%) Lacunar (25%) Other (5%) Subarachnoid (5%) Intracerebral (15%)

6 Mortality & Morbidity TACI PACI LACI POCI Proportion 25% 24% 34% 17% Death 39% 4% 2% 7% (30 Days) Independent 4% 56% 62% 62% (30 Days) Recurrence 6% 17% 9% 20% (1 Year) Bamford J et al. 1991; Lancet 337,

7 Time is Brain Every Minute 2 million neurones 14 billion synapses 8 miles of myelinated fibres

8 AF & Stroke Cardioembolism AF & Stroke Burden AF & Stroke Risk AF & Stroke Outcome

9 AF & Stroke Ischemic 80% Haemorrhagic 20% Atherothromboembolic (50%) Cardioembolic (20%) Lacunar (25%) Other Subarachnoid Intracerebral

10 AF & Stroke Burden 14% of all strokes are due to AF 16,000 strokes annually in patients with AF in England Of these approx 12,500 are though to be attributable to AF 4,300 deaths in hospital 3,200 discharges to residential care 8,500 deaths within the first year

11 AF & Stroke Burden Over 50% of AF-related stroke occurs in pts over age 75 (BAFTA study) Stroke associated with AF tends to be more severe, greater long-term disability, higher mortality Cardioembolic stroke has a 30-day mortality of 25% 1 AF-related stroke has a 1-year mortality of ~50%¹ 1. Lin H-J, et al. Stroke 1996; 27: ; 5. Marini C, et al. Stroke 2005;36:

12 AF & Stroke Risk Risk of stroke is the same in AF regardless of whether paroxysmal or sustained²³ AF is associated with a prothrombotic state ~5 fold increase in stroke risk 1 1. Wolf PA, et al. Stroke 1991;22: ; 2. Rosamond W et al. Circulation. 2008;117:e25 146; 3.Hart RG, et al. J Am Coll Cardiol 2000;35: ;

13 AF & Stroke Risk Often occurs in the atrial appendage fibrin rich Rise in coagulation and platelet activation² Stasis, endothelial dysfunction and hypercoagulable state¹ (1) Stoddard et al, J Am Coll Cardiol. 1995;25: (2) Mitusch et al. Thromb Haemost. 1996;75: (3) Fuster et al, JACC. 2006;48(4):

14 AF & Stroke Outcome 10 patients with AF will suffer a stroke within the next 4 hours 8 would have been known to be at high risk of stroke 6 should have been on anticoagulation 5 will end up in residential care 2 will die

15 Atrial Fibrillation What is it? Who gets it? AF Classification AF Consequences AF Recognition AF Diagnosis Manual Pulse Check 12 lead ECG

16 What is it? AF is the most common heart rhythm disturbance 1 It is estimated 1 in 4 individuals aged 40 years will develop AF 1 In 2007, 6.3 million people in the US, Japan, Germany, Italy, Spain, France and UK were living with diagnosed AF 2 Due to the aging population, this number is expected to double within 30 years 3 1. Lloyd-Jones DM, et al. Circulation 2004;110: Decision Resources. Atrial Fibrillation Report. Dec Go AS, et al. JAMA 2001;285:

17 Who gets it? AF prevalence (%) General population >60 years >80 years Age 1. Go AS, et al. JAMA 2001;285:

18 Who gets it? Present in 3-6% of hospital admissions Prevalence of 4.7% of people aged 65yrs or more in general practice

19 AF Recognition Perform opportunistic pulse check in those >65 particularly those patients presenting with: Breathlessness or dyspnoea Palpitations Syncope or dizziness Chest discomfort Stroke/TIA Also perform routinely when monitoring patients with: Hypertension Diabetes Existing cardiovascular disease

20 AF diagnosis MANUAL pulse checking will give a strong clue Irregular irregularity any rate Variable strength of individual pulses Often omitted since introduction of automated BP machines, etc. 12 Lead ECG NICE an ECG should be performed in all patients, whether symptomatic or not, in whom AF is suspected because an irregular pulse has been detected

21 ECG Rhythms

22 Any Comments