Epidemiology and Impact of A Little Bit of Afib" Margot E. Vloka, MD, FACC, FHRS St. Alphonsus Regional Medical Center Heart Institute Boise, Idaho

Epidemiology and Impact of A Little Bit of Afib" Margot E. Vloka, MD, FACC, FHRS St. Alphonsus Regional Medical Center Heart Institute Boise, Idaho

Disclosures: Medtronic Biotronic AtriCure

What is Atrial Fibrillation? Atrial Fibrillation is an Atrial Cardiomyopathy 1 diagnosed by ECG and characterized by an irregulary irregular rhythm. 1 Any complex of structural, architectural, contractile or electrophysiological changes affecting the atria with the potential to produce clinically - relevant manifestations 1 Goette et al. Heart Rhythm, Vol 14, No 1, January 2017

Atrial Fibrillation is an: Age Dependant, Multifactorial, Chronic, Progressive, Inflammatory, Systemic, Heritable and Heterogeneous, Dangerous Disease Leading to a: Shorter, Less Satisfactory and Frequently Disabling Life

Wolf. Arch Intern Med. 1998;158:229-34, Hubbard, M. Am J Med Qual. 2014;29: 206-12 Soliman, JAMA 2014;174:107-14, Singh-Manoux, Eur Heart J ; 2017;doi: 10.1093/eurheartj/ehx208. Patients With Atrial Fibrillation High incidence of complications Stroke rate x 5 Heart failure x 3 Extracranial systemic embolic event x 2 MyocardiaI infarction x 2 Higher mortality rate x 2 Increased cognitive impairment or dementia in stroke-free individuals especially younger than 65 Greater health care costs than patients with other forms of cardiovascular diseases

Prevalence of Atrial Fibrillation Stratified by Gender and Age Naccarelli et al., Am J Cardiol 2009;104:1534 1539

Incidence of Atrial Fibrillation Incidence of atrial fibrillation, Framingham Heart Study 38-year follow-up. Darker bars indicate men; and lighter bars, women. Adapted from: Benjamin et al. JAMA. 1994;271:840-844

Projected Atrial Fibrillation Prevalence in the United States 12.1 mln 5.1 mln 7.0 mln 6.5 mln 9.3 mln Adapted from: Colilla et al. Am J Cardiol 2013; 112: 1142-47

Projected Atrial Fibrillation Incidence in the United States 2.6 mln 500/100,000 1.2 mln Adapted from: Colilla et al. Am J Cardiol 2013; 112: 1142-47

Trends in Cancer Incidence Rates in the United States Source: J Natl Cancer Inst 2017;109 (9):1-22. Age adjusted to the 2000 US standard population.

Estimated Incidence of Cancer and Atrial Fibrillation in the United States in 2017 Every 40 seconds someone has a heart attack or stroke Every 20 seconds someone in the United States is diagnosed with Atrial Fibrillation or malignant cancer for the first time Estimated new cases for 2017 Cancer 1 Atrial Fibrillation 2 Total 1.67 mln 1.64 mln Breast 255,000 Lung and bronchus 222,000 Prostate 161,000 Colon and rectum 135,000 1 American Cancer Society, Cancer.org accessed on 06.16.2017, 2 Colilla et al. Am J Cardiol 2013; 112: 1142-47

1 Adapted from: Lloyd-Jones et al. Circulation 2004;110:1042-6, 2 American Cancer Society, Cancer.org accessed on 06.16.2017, 3 Naccarelli et al., Am J Cardiol 2009;104:1534 1539 Remaining Lifetime Risk of Developing AF 1, Cancer 2 or CVD 3 at Age of 40 Site Male Female 1 in 1 in CHD 2 3 Atrial Fibrillation 4 4 CHF 5 5 Stroke 6 5 Prostate 7 Breast 8 Lung & Bronchus 13 16 Colon & Rectum 21 23

Adapted from: Picini et al. Eur Heart J 2014;35:250-256, Mozaffarian et al. Circulation. 2015;131:e29-e322 Cumulative Incidence of Events After Diagnosis of Atrial Fibrillation In Medicare Patients 48.8%-AF 19.5%

Adapted from: Picini et al. Eur Heart J 2014;35:250-256, Mozaffarian et al. Circulation. 2015;131:e29-e322 Cumulative Incidence of Events After Diagnosis of Atrial Fibrillation In Medicare Patients 48.8%-AF 54.9% -AF + MI 65.7% -AF + Stroke 73.1%-AF + CHF 19.5%

Long-Term Cardiovascular Event Risks Associated With Atrial Fibrillation 8354 women, 7052 men, Age 45-64 y.o. followed for 20 years (27%) (45%) (66%) (89%) Cardiovascular event =hospitalizations (Myocardial Infarction, Stroke, Heart Failure) or deaths during 20-year follow-up, by the presence of Atrial fibrillation. Women five-fold increase of cardiovascular event. Men two-fold. Adapted from: Stewart et al. Am J Med. 2002;113:359-364

Long-Term Cardiovascular Event Risks Associated With Atrial Fibrillation (71% women alive) (56% men alive) (72% men died) (86% women died) Age-adjusted, sex-specific cardiovascular event (hospitalizations or deaths) during 20-year follow-up, by the presence (n 100) or absence (n 15,306) of atrial fibrillation at baseline. CV Hospitalizatiom (Acute Miyocardial Infarction, Stroke,Heart Failure Adapted from: Stewart et al. Am J Med. 2002;113:359-364

5-Year Survival By Primary (Invasive) Cancer Site In the United States 2003-2009 1. PANCREAS 2. MESOTHELIOMA 3. BRAIN & CNS 4. LIVER & IBD 5. LUNG & BRONCHUS 6. ESOPHAGUS 7. STOMACH 8. OVARY 9. MYELOMA 10. CERVIX UTERI ATRIAL FIBRILLATION 11. HODGKIN LYMPHOMA 12. ORAL CAVITY & PHARYNX 13. RECTUM 14. NON-HODGKIN LYMPHOMA 15. COLON 16. KIDNEY&RENAL PELVIS 17. CHRONIC LYMPHOCYTIC LEUKEMIA 18. URINARY BLADDER 19. CORPUS UTERI 20. KAPOSI SARCOMA 21. MELANOMA 22. TESTIS 23. BREAST 24. THYROID 25. PROSTATE ATRIAL FIBRILLATION OVERALL 4.1 5.7 7.0 10.2 14.9 15.4 23.9 27.5 33.4 47.5 51.2 52.4 53.8 Adapted from: Piccini, Eur Heart J 2014; 35, 250-256. Howlader N Cancer Statistics Review, 1975-2010, NCI. Bethesda, MD, http://seer.cancer.gov/csr/1975_2010/ 51.2 60.2 60.6 62.6 64.5 58.7 73.4 74.7 73.2 88.2 88.4 88.6 88.9 91.1 99.2

The Most Common Comorbid Chronic Conditions Among Medicare Beneficiaries Beneficiaries 65 y.o. With AF* (N=2 556 839) With HF* (N=4 366 489) With Stroke* (N=1 145 719) With IHD* (N=8 678 060) % % % % Hypertension 84.5 85.6 89.0 81.3 IHD 63.8 62.6 58.1 Index Heart Failure 50.9 Index 37.2 36.3 Diabetes Mellitus 37.1 47.1 41.5 41.7 CKD 34.4 44.8 35.2 30.2 COPD 23.8 30.9 # 21.0 AF Index 28.8 # 18.7 Stroke # # Index # AF-Atrial Fibrillation, IHD-Ischemic Heart Disease, CKD-Chronic Kidney Disease, COPD-Chronic Obstructive Pulmonary Disease, *Data shown as a percentage of persons with index condition who also had a comorbidity, #-Not in top 10 comorbidities Modified from: Arnett et al, Circulation 2014;130:1662-1667, CMS, Chronic Conditions Among Medicare Beneficiaries Chartbook, 2012 Edition. Baltimore, MD. 2012,. Hubbard, M. Am J Med Qual. 2014;29:206 212

Causes of Death in Patient with Atrial Fibrillation Cardiac 46.00% sudden cardiac death 28.00% heart failure 15.00% myocardial infarction 3.00% Non-Vascular 29.79% cancer 11.00% infections 9.00% Ischemic Stroke/SE 5.74% Bleeding 5.64% Adapted from: Gomez-Outes et al. J Am Coll Cardiol 2016;68(23):2508 21

Conclusions: Atrial Fibrillation is an Atrial Cardiomyopathy We are in the middle of a global Atrial Fibrillation Epidemic There is a need to identify interventions beyond effective anticoagulation to further reduce mortality and morbidity in atrial fibrillation patients.

Co-morbidity among Chronic Conditions for Medicare FFS Beneficiaries: 2010 Centers for Medicare and Medicaid Services. Chronic Conditions among Medicare Beneficiaries, Chartbook, 2012 Edition. Baltimore, MD. 2012

Spending on Medicare Services as a Percentage of Total Medicare Spending Among Medicare FFS Beneficiaries by Number of Chronic Conditions: 2010 Centers for Medicare and Medicaid Services. Chronic Conditions among Medicare Beneficiaries, Chartbook, 2012 Edition. Baltimore, MD. 2012

Four Stages of Left Atrial (LA) Structural Remodeling (SRM) Based on 3-dimensional Late Gadolinium Enhancement MRI Christopher McGann et al. Circ Arrhythm Electrophysiol. 2014;7:23-30 Copyright American Heart Association, Inc. All rights reserved. 23

Atrial Fibrillation Management Center Neurology EP PCP Cardiology AF AF Patient Patient Pulmonary Cardiothoracic Surgery Endocrinology ER