Atrial Fibrillation Detection in the Community and Hospital settings

Transcription

1 Atrial Fibrillation Detection in the Community and Hospital settings Shuja Punekar Consultant Cerebrovascular Physician Hon Senior Lecturer, Manchester Medical School

2 How common is AF in the population Permanent vs Paroxysmal AF Subclinical forms of AF and risk of stroke Are there certain groups of patients or certain areas where we may find more than the usual number of AF patients? How can we improve identifying all patients with AF?

3 What do the 3 slides show What is the unifying pathology

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5 Prevalence of AF by age groups in the Rotterdam study European Heart Journal (2006) 27,

6 Heart 2001;86: Prevalence of AF in Scotland Age and sex specific figures from the Renfrew Paisley study from the West of Scotland. Note this study does not include patients 65 years of age or older

7 Approximate Prevalence of AF by age groups

8 Life Time Risk of AF at age 55 Is approx 1 in 4 Men Women 23.8% 22.2% European Heart Journal (2006) 27,

9 Heart 2001;86: Clinical Predictors for AF from the Renfrew Paisley study Cardiomegaly On CXR; Odds ratio 14 Systolic BP Odds ratio 2.1 for SBP >/= 169 mm Hg

10 Permanent AF Paroxysmal AF Subclinical AF

11 NICE recommends anticoagulation for eligible patients whether they have permanent or paroxysmal AF

12 N Engl J Med 2012;366: Sub clinical AF Sub clinical tachyarrhythmias were associated with an increased risk of Clinical AF and of Ischaemic Stroke and systemic thromboembolism

13 Warfarin reduces Stroke risk by 62% Aspirin reduces Stroke risk by 22%

14 NNT NNT to prevent 1 stroke per year of anticoagulation therapy in secondary prevention (ARR: 8.5%) = 12 NNT for Secondary Prevention = 12 NNT in primary prevention = 37 NNT for Primary Prevention = 37 HEARTJNL/2005/066944

15 How good are we in achieving target INR in patients on warfarin

16 In most RCTs we see Time in Therapeutic Range (TTR) to be between % as demonstrated here for AF patients on oral anticoagulation. Circ Cardiovasc Qual Outcomes 2008;1;84-91;

17 Circ Cardiovasc Qual Outcomes 2008;1;84-91; Time in therapeutic range (TTR) predicts adverse outcomes both thromboembolic and haemorrhagic in AF patients on oral anticoagulation (weighted sample sizes); p values were significant for retrospective studies and not RCTs; Graph shows all studies - big circles are mostly RCTs

18 Risk of Intracranial haemorrhage rises steeply for INRs over the therapeutic range (Q J Med 2011; 104: )

19 Improving Detection of AF in Hospitals Acute Hospitals offer a great opportunity to detect almost all patients with AF and commence adequate antithrombotic/anticoagulant therapy

20 Prevalence of AF in Acute Prevalence Medical admissions in Preston 500 consecutive acute medical admissions at RPH were screened for AF 50 years of age or over between 11 May and 1 June had AF; Prevalence = 20.4% 59% were F and 41% M Mean age was 78 Lucy Freeman, Shuja Punekar Awarded best student oral presentation at the UK Stroke Conference Nov/Dec 2010

21 Spread of CHADS2 scores No >75% of AF patients from the medical admissions study scored 2 or more on CHADS2 Lucy Freeman, Shuja Punekar. 2010

22 Type of AF Number of patients New onset 26 Permanent 57 Paroxysmal 16 Persistent 1 Lucy Freeman, Shuja Punekar. 2010

23 Warfarin Aspirin+ None As many as 50% of patients were discharged only on Aspirin or no antithrombotic therapy at all Lucy Freeman, Shuja Punekar. 2010

24 Improving Detection of AF the Community

25 Opportunistic Screening Take a pulse For eg on all patients attending Flu vaccinations at your practice and then confirm AF with an ECG if the pulse is irregular

26 Colchester PBC Group incentivised 37 practices out of 43 to carry out screening of patients at Flu clinics for AF. These 37 practices screened 34,201 patients in six weeks, detecting 189 new patients with AF. The project prevented an estimated five strokes, representing an annual saving of 220,000 a 322 per cent return on investment in addition to improved quality outcomes. 5 August 2010 Health Service Journal 25

27 AF in Care Homes

28 AF in Care Homes Study Carried out in Care homes in Preston(May-June 2011) McCrory S, Punekar SN; 2011

29 Prevalence of AF in RH/NH homes by age groups AF% AF in Nursing/Care Homes Study Prevalence of AF was similar to that found in other studies on the general population. McCrory Simon, Punekar Shuja. Unpublished data

30 AF in the hospitalised elderly

31 A cross sectional survey was carried out at RPH on the 30 th Jan 2012 and all elderly patients 75 years of age or over admitted in 4 medical wards were assessed for presence of AF and their CHADS2 scores

32 Total No of patients 55 Mean age 85 years Male/Female 25/30 45%/55% Patients with AF 22 40% Patients with AF & CHADS2 score of 2 or more % 40% of hospitalised elderly(75+yrs) were in AF and nearly 90% of those had a CHADS2 score of 2 or above

33 Learning points Hospitalised elderly (75+) have a very high risk of being in AF 40% Hospitalised elderly patients with AF invariably have high CHADS2 scores

34 Turning the CHADS2 on it s head and using it to detect AF instead

35 Those who had a CHADS2 score of 2 or more were more likely to have AF vs those whose CHADS2 was <2 (48.72% vs 18.75% )

36 Is there evidence that we can improve outcomes by managing the risk factors

37 Lancet 2004; 363: Age-specific incidence rates of non-minor Stroke in the OCSP(1981) and the Oxvasc(2004) studies in Oxford showing a significant decline As shown here the incidence of Stroke is improving in the general population

38 Stroke Mortality is Falling in England Age-standardized mortality rates in the Oxford region 1979 to 2004 (with 95% confidence intervals) and England 1996 to 2004, comparing underlying cause and mentions. Underlying cause as mentioned in the death certificate; Mentions = any mention on the death certificate Stroke. 2008;39:

39 Cardiovascular and Stroke Mortality in Lancashire CVD Mortality - rate /000 popn - All persons under 75 Chorley Preston South Ribble West Lancashire Central Lancashire England Source: Central Lancs PCT Data includes Stroke, IHD and all cardiovascular causes Per 100,000 population

40 Why is the incidence of Stroke (and CV disease) improving

41 Premorbid medication in Incident first-ever TIA or Stroke in the OCSC and OxVasc studies Note the rise in all Medications. (Primary prevention is in patients with no previous evidence of vascular disease.) We are managing risk factors much better now Lancet 2004; 363:

42 Thank you