ATRIAL FIBRILLATION 2014

GP Update November 2014

Dr Philippa HowlettClinical Research Fellow

OVERVIEW

• Clinical impact• Epidemiology• AF subtypes

• Diagnosis• Management

– Prevention of thromboembolism– Rate and rhythm control

• NICE guidelines

MORBIDITY AND MORTALITY

EPIDEMIOLOGY

Miyasaka et al

EVOLUTION OF AF

PAROXYSMAL AF

• Defined as AF with a duration 30 seconds to 7 days with spontaneous termination.

• Approximately 50% of all cases of AF

• Difficult to diagnose due to intermittency

• Generally thought to confer equivalent TE risk

AF SCREENING

• The ‘pulse-check’ 94% sensitivity and 73% specificity for AF (Cook et al)• Stroke-Stop (Friberg et al)

– 5% new AF cases in asymptomatic 75-76 year-olds in Sweden. 2 week intermittent use of hand-held ECG monitor.

• Search-AF (Lowres et al)– AliveCor AF screening of 1000 people aged

65 years and over in pharmacies in Australia. Mean age 79 years. Prevalence 6.7%, new AF in 1.5%.

• Hospital screening (Samol et al)– Use of hand-held ECG in high-risk clinics (hypertension, dyslipidaemia,

diabetes clinics). Mean age 64 years. New AF detected in 5.3%.

NICE GUIDELINES - DIAGNOSIS

• Perform pulse palpation in people presenting with dyspnoea, palpitations, syncope or dizziness

• Arrange an ECG when an irregular pulse has been detected

• In those with suspected PAF:– Use 24 hour ambulatory ECG in those with suspected asymptomatic

episodes or symptomatic episodes less than 24 hours apart– Use an event recorder ECG in those with symptomatic episodes more

than 24 hours apart

(NICE guidelines CG180 - June 2014)

HASTENinGS

p = 0.03

HASTENinGS

p < 0.001

PREDICT-PAF

Left atrium

ANTITHROMBOTIC THERAPY

Hart et al

THROMBOEMBOLIC RISK

Lip et al

WARFARIN & TTR

Oden et al

TIME IN THERAPEUTIC RANGE (TTR)

• Decision support software: TTR = 73% in 3600 patients in New Zealand (Harper et al)

• Patient self-testing: Significant reduction in mortality (OR = 0.74) and thromboembolism (OR = 0.56) in one meta-analysis. (Bloomfield et al)

• Single educational intervention: Significant increase in TTR at 6 months (76% vs 71%) (Clarkesmith et al)

NOVEL ORAL ANTICOAGULANTS

NOVEL ORAL ANTICOAGULANTS

Ruff et al

NICE GUIDELINES – CHA2DS2-VASc

• Use the CHA2DS2-VASc risk score and HAS-BLED scores to estimated TE and bleeding risk

• Consider OAC in those with CHA2DS2VASc = 1

• Offer OAC to those with CHA2DS2VASc ≥ 2

• Anticoagulation ‘may be with apixaban, dabigatran, rivaroxaban or a vitamin K antagonist’.

(NICE guidelines CG180 - June 2014)

NICE GUIDELINES - TTR

• In those receiving a VKA calculate TTR at each visit and at least annually

• Reassess anticoagulation if: x2 INR >5 or x1 INR >8 in last 6 months; x2 INR < 1.5 in last 6 months or TTR < 65%

• Recommends point-of-care coagulometers for ‘self-monitoring for people on long-term anticoagulation therapy’ e.g. Coaguchek XS system and INRatio2 PT/INR Monitor

(NICE guidelines DG14 September 2014)

RATE AND RHYTHM

RATE VS RHYTHM CONTROL

ANTI ARRHYTHMICS

DC CARDIOVERSION

Sandler

CATHETER ABLATION

• Global registry (Cappato et al)

– Efficacy 75% in PAF, 65% in sustained AF at minimum 4 months

– Significant complications in 4.5% including stroke (0.23%), tamponade (1.3%), pulmonary vein stenosis (0.29%)

NICE GUIDELINES – RATE CONTROL

• Rate-control as first-line strategy unless rhythm control is appropriate based on clinical judgment.

• Initial monotherapy includes a standard beta-blocker of rate-limiting calcium channel blocker

• Consider combination therapy if monotherapy does not control symptoms

(NICE guidelines CG180 - June 2014)

NICES GUIDELINE - RHYTHM CONTROL

• Consider pharmacological or electrical rhythm control in those whom rate-control has been unsuccessful.

• Also offer rhythm control in the following cases:– AF with a reversible cause– Cardiac failure caused by AF– New onset AF– Atrial flutter potentially suitable for ablation– When a rhythm control strategy would be more suitable based on clinic

judgement

• In the event of failure of drug treatment: ‘offer left atrial catheter ablation to patients with paroxysmal AF and consider in those with persistent AF’.

(NICE guidelines CG180 - June 2014)

CONCLUSIONS

HASTENinGS REFERRAL CRITERIA

http://hasteacademy.org/forms

REFERENCES- Bloomfield HE, Krause A, Greer N, et al. Meta-analysis: effect of patient self-testing and self-management of long-term anticoagulation on major clinical outcomes. Intern Med 2011; 154(7):472-482- Cappato R, Calkins H, Chen S, et al. Updated Worldwide Survey on the Methods, Efficacy and Safety of Catheter Ablation for Human Atrial Fibrillation. Cir Arrhythm Electrophysiol 2010; 3: 32-38- Clarkesmith DE, Pattison HM, Lip GYH, et al. Educational Intervention Improves Anticoagulation Control in Atrial Fibrillation Patients: The TREAT Randomised Trial. PLOS One 2013; 8(9):e74037- Clua-Espuny J, Lechuga-Duran I, Bosch-Princep R, et al. Prevalence of undiagnosed atrial fibrillation and of that not being treated with anticoagulant drugs: the AFABE Study. Rev Sep Cardiol 2013; 66(7):545-552- Cooke, G., Doust, J. Is pulse palpation helpful in detecting atrial fibrillation? A systematic review. Journal of Family Practice 2006;55(2): 130-4 - Friberg L, Engdahl J, Frykman V et al. Population screening of 75- and 76-year old men and women for silent atral fibrillation (STROKESTOP). Europace 2013; 15(1):135-40- Harper P, Harper J, Hill C. An audit of anticoagulation management to assess anticoagulant control using decision support software. BMJ Open 2014; 4: e005864- Jabaudon, D., Sztajel, J. et al. Usefulness of ambulatory 7-day ECG monitoring Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have non-valvular atrial fibrillation. Ann Intern Med 2007; 146: 857-867- Lin HJ, Wolf PA, Kelly-Hayes M, et al. Stroke Severity in Atrial Fibrillation – The Framingham Study. Stroke 1996; 27: 1760-1764

REFERENCES- Lip GY, Niewwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach. Chest 2010; 137(2): 263-272 - Lowres N, Freedman SB, Redfern J, et al. Screening Education And Recognition in Community pHarmacies of Atrial Fibrillation to prevent stroke in an ambulant population aged ≥ 65 years (SEARCH-AF stroke prevention study): a cross-sectional study protocol. BMJ Open 2012; 2:e001355 doi:10.1136/bmjopen-2012-001355- Miyasaka Y, Barnes ME, Bailey KR, et al. Mortality trends in patients diagnosed with first atrial fibrillation: a 21-year community-based study. J Am Coll Cardiol 2007; 6(49): 986-992- Oden A, Fahlen M, Hart RG. Optimal INR for prevention of stroke and death in atrial fibrillation: a critical appraisal. Thrombosis Research 2006; 117(5): 493-499- Ruff CT, Giugliano RP, Brainwald E, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet 2014; 383(9921): 955-962- Samol A, Masin M, Gellner R, et al. Prevalence of unknown atrial fibrillation in patients with risk factors. Europace 2013; 15(5): 657-62- Sandler DA. Whatever happens to the cardioverted? An audit of the success of direct current cardioversion in a district general hospital over a period of four years. Br J Cardiol 2010; 17:86-88