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Diagnosing Heart Arrhythmias in Diabetes and Hypertension

Explore the importance of diagnosing heart arrhythmias in patients with diabetes and hypertension. Learn about the risks and symptoms, and discover the impact on mortality rates.

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Diagnosing Heart Arrhythmias in Diabetes and Hypertension

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  1. www.epccs.eu Diabetes and hypertension When does diagnosing heart arrythmias matter? Prof John Camm London, United Kingdom

  2. MarketScan & Thomson Reuters Medicare databases, 20091 Olmsted County data, 2006 (assuming a continued increase in the AF incidence)2 Olmsted County data, 2006 (assuming no further increase in the AF incidence)2 ATRIA study data, 20003 7.56 3.03 Projected Number of Patients With AF by 2050 1. MarketScan & Thomson Reuters Medicare databases, 2009. 2. Miyasaka Y et al. Circulation 2006; 114: 119–125. 3. Go AS et al. J Am Med Assoc 2001; 285: 2370–2375.

  3. Lifetime Risk of AF • Overall lifetime risk for AF is one in four for men and women aged 40 • Even in the absence of CHF or MI, lifetime risk for AF is still very high (one in six) Framingham 30 26.0 25.9 25.8 24.3 23.4 23.0 23.2 23.0 22.7 21.6 25 20 Lifetime risk of AF (%) Women 15 Men 10 5 0 40 50 60 70 80 Age (years) Lloyd-Jones DM, et al. Circulation 2004; 110: 1042–46

  4. What are the Symptoms of AF? • Symptoms may be experienced on a regular basis, intermittently, or not at all:1,2 • Fatigue • Palpitations • Dizziness • Chest pains • Breathlessness Many people with atrial fibrillation lack any symptoms1,2 • Atrial fibrillation is diagnosed by ECG 3 • http://www.nhlbi.nih.gov/health/dci/Diseases/af/af_what.html; • http://www.patient.co.uk/health/Atrial-Fibrillation.htm; • Ashley EA & Niebauer J. Cardiology explained. Remedica: London 2004.

  5. Symptomatic Silent Atrial Fibrillation Symptomatic -v- Asymptomatic Cardiovascular Health Study Prevalence of AF (%) 10 Asymptomatic 8 Symptomatic 6 All Women 4 2 0 “Its only the tip of the iceberg” 65-69 70-79 80+ Edward J Smith, Captain of the Titanic Age Group Savelieva I, et al. Pacing Clin Electrophysiol 2000; 23: 145–8;Furberg C, et al. Am J Cardiol 1994; 74: 236–41; Page RL, et al.

  6. Silent AF in Olmsted County • 4618 residents with 1st AF • 23% silent • 35% non-specific symptoms • 18% typical symptoms • Silent AF survival no different to symptomatic AF 1980-84: 173/726 (24%) 1985-89: 188/833 (23%) 1990-94: 259/1066 (24%) 1995-00: 318/1492 (21%) Barnes et al, JACC 2005

  7. 80 80 70 70 60 60 50 50 40 40 30 30 20 20 10 10 0 0 0 1 2 3 4 5 6 7 8 9 10 0.5 1.5 2.5 3.5 5 0 1 2 3 4 4.5 Years of follow up Years of follow up Risk of Mortality with AF Framingham Data Age 55–74 years Age 75–94 years • AF approximately doubles the risk of mortality in both younger and older patients1 • Two-thirds of deaths in AF patients can be attributed to CV causes2 • Risk of death is similar for men and women with AF3 Men AF (n=53) Log rank 42.90 (men) 70.93 (women) Log rank 51.44 (men) 101.51 (women) Women AF (n=47) Men no AF (n=6999) Subjects dead in follow up (%) Women no AF (n=8307) 1. Benjamin EJ, et al. Circulation 1998; 98: 946–52; 2. Lévy S, et al. Circulation 1999; 99: 3028–35; 3. Stewart S, et al. Am J Med 2002; 113: 359–64

  8. “3 P” Classification Acute Chronic versus First Onset Paroxysmal Recurrent Persistent Permanent Camm AJ. PACE 1997; 20:1603-5 

  9. Multi-dimensional Classification of AF Atrial remodeling Much Risk score High Little Low None Many Symptoms 6P Classification + Camm AJ, et al. Am Heart J. 2013;164:292-302

  10. Progression of Atrial Fibrillation Electrical AF Anatomical AF Muscle Fibrosis Mahnkopf et al. Heart Rhythm 2010

  11. AF, Diabetes and HypertensionThe ALFA Study Levy S, et al. Circulation.1999; 99: 3028-3035

  12. Prevalence of Common Co-morbidities AF and Non-AF Patients AF only 70 AFL only AF and AFL 60 Matched controls 50 40 Individuals with condition (%) 30 20 10 0 Stroke CHF VHD CAD PVD Lung disease Thyroid disease DM HTN n=242,903 with non-transient AF/AFL Naccarelli GV, et al. J Am Coll Cardiol 2009;53:A104-5

  13. Prevalence of AF by Age and Diabetes 10,213 members of HMO diabetes registry matched to patients without diabetes on year of birth and sex. All patients were followed until they died, left the health plan, or until study end  26% increased risk of AF among women (hazard ratio 1.26 [95% CI 1.08–1.46]) Nichols G A et al. Dia Care 2009;32:1851-1856

  14. Type 2 Diabetes and AF Meta-analysis Relative risk (95% CI) • 7 prospective cohorts, 4 case-control studies • No AF: 1,686,097 • AF: 108,703 • Population-attributable effect 2.5% (0.1-3.9%) Frost (men), 2005 Frost (women), 2005 Rosengren, 2009 Smith (women), 2010 Krahn, 1995 Benjamin (men), 1994 Benjamin (women), 1994 Smith (men), 2010 Ruigomez, 2002 Watanabe, 2009 Johansen, 2008 Dublin, 2010 Nichols (women), 2009 Nichols (men), 2009 Movahed, 2005 Cohort 1.32 (1.09 - 1.6) p = 0.016 Case- control 1.53 (1.03 - 2.26) p = 0.000 1.39 (1.1 - 1.75) p = 0.000 .2 .33 .5 1 2 3 4 5 DM  AF DM  AF Huxley RR, et al. Am J Cardiol 2011;108:56-62 p <0.001 for heterogeneity

  15. 4-y Risk of CVD by the ADVANCE Model Equation 4.5-year FU of the Action in Diabetes and Vascular disease: (ADVANCE) Coefficients for significant predictors of CVD using Cox regression 473 major CV events were recorded during follow-up AF doubles risk Kengne A P et al. European Journal of Cardiovascular Prevention & Rehabilitation 2011;18:393-398

  16. 100 DM, no SAF 5.9% DM, SAF 17.3% 80 Stroke free survval, % HR = 4.6 (2.7 – 9.1) p <0.001 Months Silent Atrial Fibrillation and Risk of Stroke in Type 2 Diabetes • Longitudinal observational study • 464 patients with DM, age < 60 yrs • 240 matched non-DM • 48-h Holter quarterly • Mean follow-up 37 months Silent infarct on MRI DM vs non-DM: 41% vs 0.5% SAFE vs no SAFE: 61% vs 29% New AF SAFE vs no SAFE: 13% vs 4% Anticoagulated: 15% with SAFE Marfella R, et al. JACC 2013;62:525-30

  17. The Risk for AF increases with Each Contributing Risk Factor The Framingham Heart Study: n=4,764 35 30 Woman 25 Men 20 10-year risk of atrial fibrillation (%) 15 10 5 0 Schnabel RB. Lancet 2009;373:739-45

  18. Baseline Characteristics All had a history of hypertension Healey J, et al. N Engl J Med. 2012;366:120-9

  19. ASSERT Study: Ischemic Stroke or Systemic Embolism 0.10 1.5 # at Risk Year 0.5 1.0 2.0 2.5 + 261 249 238 218 178 122 _ 2145 1556 1197 2319 2070 1922 0.08 RR=2.49 95%CI 1.28-4.85 P=0.007 0.06 Device-Detected Atrial Tachyarrhythmia Detected 0-3 months Cumulative Hazard Rates 0.04 AHRE(>6 minutes,>190/minute) 0.02 No Asymptomatic Atrial Tachycardia Detected 0-3 months 0.0 0 0.5 1.0 1.5 2.0 2.5 T0 at 3-month visit Years of Follow-up Healey J, et al. N Engl J Med. 2012;366:120-9

  20. Primary and Other Clinical Outcomes Healey J, et al. N Engl J Med. 2012;366:120-9

  21. Clinical Outcomes CHADS2 ≥ 2 Healey J, et al. N Engl J Med. 2012;366:120-9

  22. Incidence Rates of Thromboembolism Among Men and Women with AF not taking Warfarin * * CHADS2 score calculated by assigning 2 points to prior stroke or transient ischemic attack and 1 point to any of the following risk factors: congestive heart failure, hypertension, age ≥75 years, and diabetes mellitus Fang M, et al. Circulation 2002:112:1687-91

  23. CHADS2 and Stroke Risk All patients with AF not treated with VKAs in Denmark 1997–2006 CHADS2 score = 0 HF Hypertension Diabetes mellitus Age ≥75 years 100 90 80 70 60 0 Hypertension Proportion of patients freeof thromboembolism (%) Diabetes 0 2 4 6 8 10 Years of follow-up Kaplan-Meier estimate of probability of remaining free of thromboembolism with CHADS2 score 0 and 1. Only patients with CHADS2 scores 0 and 1 were included, and patients were censored at death for causes other than thromboembolism Olesen JB et al, BMJ 2011;342:d124. VKA, vitamin K antagonist

  24. Management of AF in DM Because AF is asymptomatic, or only mildly symptomatic, in a substantial proportion of patients (about 30%), screening for AF can be recommended in selected patient groups with T2DM with any suspicion of paroxysmal or permanent AF by pulse palpation, routine 12-lead ECG, or Holter recordings. Ryden L, et al. doi:10.1093/eurheartj/eht108 - Advance Access published Aug 30, 2013

  25. ESC AF Guideline Update - 2012

  26. Diagnostic Accuracy Irregular Pulse for AF Diagnostic accuracy of 3 different methods of pulse palpation to screen for the presence of AF. Method 1: diagnostic accuracy based on the detection of any pulse irregularity; method 2: diagnostic accuracy based on the detection of frequent or continuous irregularities; method 3: diagnostic accuracy based on the detection of only continuous irregularities Fitzmaurice et al, BMJ 2005

  27. MyDiagnostick • Acquires a one minute ECG (Lead I) • Performs ECG analysis and provides diagnostic outcome directly after ECG acquisition • Diagnostic outcome is simply red (AF) or green (No AF) easy interpreted by physician and patient • Web-portal for ECG viewing, storage and management

  28. Action in the Community • Take the pulse • Record ECG

  29. Follow-up AF Detection Depends on Monitoring Strategy Estimated correlation between follow-up technique and AF recurrence following catheter ablation Mobile cardiac outpatient monitoring 100% Implanted device† Daily Tele-ECG 7-day-ECG* 24-hour-ECG* Detection of AF recurrences Tele-ECG* ECG* *During 3-month follow-up †As the theoretical gold standard Tele = transtelephonic After Arya A et al. Pacing Clin Electrophysiol. 2007;30:458-62.

  30. Heart Failure Incidence Trends from First AF Time Trends of Ischemic Stroke After First AF Age- and gender-adjusted P=0.86 Age- and gender-adjusted P=0.0001 Cumulative incidence of CHF (%) Cumulative incidence of stroke (%) Years after first AF diagnosis Years after first AF diagnosis Miyasaka et al: EHJ 27:936, 2006 Miyasaka et al: Stroke 36:2362, 2005 Trends in AF Outcomes

  31. Apixaban and All-cause Mortality in AF Imputed analysis using data from AVERROES and meta-analyses of warfarin vs placebo studies and aspirin vs placebo studies Odds ratio Warfarin meta-analysis P = 0.004 ARISTOTLE - imputed Aspirin meta-analysis P = 0.02 AVERROES - imputed P = 0.0002 ARISTOTLE + AVERROES imputed 0.25 0.5 1 2 Favours active therapy Favours placebo/control Data suggest that apixaban reduces all-cause mortality by ≈1/3 in AF patients McMurray JJV, et al. ESC 2012

  32. LIFE Study 1o EP: CV mortality, stroke, MI, % 9193 HTN, 8804 no AF 50 HR 0.67 [0.55-0.83], p < 0.001 40 30 Atenolol Losartan 20 10 0 0 12 24 36 48 60 72 Months Losartan in Hypertensive Patients:Preventing AF and Improving Outcome in AF Patients with AF HR 0.58 (95% CI, 0.39 – 0.87) p = 0.009 Incidence of AF,% 8 6 Atenolol 10.1% per 1000 patient-years 4 2 Losartan 6.8% per 1000 patient-years 0 0 6 12 18 24 30 36 42 48 54 60 66 Months Wachtell K, et al, JACC 2005;45:705-11

  33. Lower Risk of Stroke After Ablation: Intermoutain Experience Incidence of CVA, % Ablation vs no ablation HR = 1.68, p <0.0001 No AF Event-free (CVA) survival AF, ablation AF, no ablation Log rank p <0.0001 Days to CVA • Intermountain AF Study • n = 37,908; mean age: 65  13 years • Ablation: n = 4,212 • Matched AF pts w/o ablation: n = 16,848 • Matched controls w/o AF: n = 16,848 • Follow-up: > 3 years • OAC in all pts with CHADS2 > 2 Bunch TJ, et al. JCE 2011;22:839-45

  34. Take Home Points • AF is a highly prevalent condition • Hypertension, diabetes and other underlying disease increase the likelihood of AF • AF worsens the stroke risk in patients with diabetes and hypertension • Pulse palpation and ECG recording may diagnose otherwise silent (asymptomatic) AF • Efficient anticoagulation and other treatments can significantly reduce the stroke risk

  35. Thank you for your attention

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