Stroke Prevention in Atrial Fibrillation How can the Pharmacy Technician help? Jill Walton-Nevins Cardiovascular Advis

1. Stroke Prevention in Atrial Fibrillation How can the Pharmacy Technician help?Jill Walton-NevinsCardiovascular AdviserBoehringer Ingelheim

8. Incidence and prevalence… • AF is the most common heart rhythm disturbance4 • It is estimated 1 in 4 individuals aged 40 years will develop AF4 • In 2007, 6.3 million people in the US, Japan, Germany, Italy, Spain, France and UK were living with diagnosed AF5 • Due to the aging population, this number is expected to double within 30 years6 4. Lloyd-Jones DM, et al. Circulation 2004;110:1042-1046. 5. Decision Resources. Atrial Fibrillation Report. Dec 2008. 6. Go AS, et al. JAMA 2001;285:2370-2375.

9. Relationship to age… Projected Number of Persons With AF in the United States Between 2000 and 2050 Age- and Sex-Adjusted Incidence of AF in 1995-2000 Millions Year 1. Miyasaka Y et al. Circulation. 2006;114:119-125.

10. Risk Factors… Cardiac • Atrial hypertrophy • Ischaemic heart disease • Rheumatic heart disease • Hypertension • Sick sinus syndrome • Wolf-parkinson-white Non-Cardiac • Acute infections (pneumonia) • Electrolyte imbalances • Lung cancer • Pulmonary embolism • Thyrotoxicosis 7.Maurits A et al. Pathophysiologyand prevention of atrial fibrillation. Circulation 2001;103:769-777

11. Types of atrial fibrillation… Classification of AF subtypes First diagnosed episode of atrial fibrillation Paroxysmal (usually ≤48 Hrs) Persistent (requires CV) Long Standing (persistent > 1year) Permanent (accepted) 11.www.escardio.org/guidlines. European Heart Journal (2010) 31, 2369-2429.

12. Symptoms… If sustained AF: • Palpitations +/- Chest pain • Dyspnoea +/- Dizziness • Reduced exercise tolerance (often significant) • Panic attacks/Agoraphobia/depression If Paroxysmal: • As above, but may be more severe (less well tolerated) • Often preceded by exertion, ‘thump’ in the chest, fatigue, alcohol, coffee and other stimulants 12.Weert, H. Diagnosing atrial fibrillation in general practice. BMJ. 2007. 335:355-356.

13. Primary care… 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

14. 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

15. Taking the pulse...

16. The radial pulse… • Very easy to do with practice • 2 or 3 fingers (not thumb) • Along radius (in line with the patient’s thumb) • 30 secs usually sufficient Give it a go!

17. Stroke risk assessment with CHADS2 *Adjusted stroke rate = expected stroke rate per 100 patient-years based on exponential survival model, assuming aspirin not taken Gage BF et al. JAMA 2001;285:2864–70

18. Stroke risk assessment with CHA2DS2-VASc *Theoretical rates without therapy corrected for the % of patients receiving aspirin within each group, assuming 22% reduction in risk with aspirin TE = thromboembolism Lip GYH et al. Chest 2010; 137;263-272.

20. AF – The real cost… • AF is a major independent risk factor of stroke with the risk increasing with age 14 • Stroke is the third most common cause of death in the UK 15 14. NICE AF June 2006. 15. National stroke strategy, Dec 2007.

21. Any Questions?

22. Stroke… ‘A clinical syndrome characterised by rapidly developing clinical symptoms and/or signs of focal and at times global loss of cerebral function, with symptoms lasting more than 24 hours or leading to death, with no apparent cause other than that of vascular origin’. (Hatano 1976) Warlow C et al. (2008). Stroke Practical Management: 39–40

23. Defining the difference…

24. Transient ischaemic attack - TIA • Stroke like symptoms but lasting less than 24 hours.1 • Most last for 15-30 minutes.1 • Symptoms completely resolved once flow returns.1 • Brain is temporarily deprived of blood by tiny emboli which break up very quickly. “angina of the brain”. 1 TIA’s do not result in permanent damage but are a warning sign of further events.1 1. Stroke Association 2010; 2. Choi J Y; 2003

25. TIA’s are a warning of a stroke • Following a TIA: • 8-12% another TIA or stroke in 1st week • 15% by one month • 30% in 5 years • Need for investigation and secondary prevention BMJ 2004; 328:326-8

26. Transient Ischaemic Attack - TIA • Health Leader 2003; University of Texas Health Science Centre at Houston

27. Stroke Epidemiology… • Each year in the UK an estimated 150,000 people have a stroke and over 67,000 of these will die as a result. This equates to one person every 5 mins. • Stroke accounts for 9% of all deaths in men and 12% of deaths in women in the UK and is the leading cause of long term disability. ‘What is a stroke?’ 2010 Stroke Association.

28. People of African or Caribbean origin and men of south Asian origin are more likely to have a stroke than people from other ethnic groups.2 • A quarter of stroke occur in people under the age of 65.2 • Strokes are the third most common cause of death in the UK1 National Audit Office. Progress in improving stroke care. 2010 2 ‘What is a stroke?’ 2010 Stroke Association. 1

29. It was estimated that in 2008-09 the direct care cost of stroke was at least £3 billion annually, within a wider economic cost of about £8 billion. • Around 300,000 people are living with moderate to severe disabilities as a result of stroke. • Without preventative action, there is likely to be an increase in strokes as the population ages National Audit Office. Progress in improving stroke care. 2010

30. Risk Factors… Stroke, like heart attack, is a vascular disease risk factors include: Hypertension Dyslipoproteinaemia Atrial Fibrillation Diabetes Smoking Unhealthy diet or high alcohol intake Previous stroke or TIA Family history National Audit Office. Progress in improving stroke care. 2010

31. AF & Stroke Burden • 12,500 strokes annually in England in patients with AF 1 • The cost per stroke due to AF is estimated to be £11,900 in the first year after stroke occurrence 1 • AF-related stroke has a 30-day mortality of around 25% 2 • AF-related stroke has a 1-year mortality of around 50% 2 • Ref 1: Commissioning for Stroke Prevention in Primary Care - The Role of Atrial Fibrillation. 2009. www.improvement.nhs.uk • Ref 2: Marini C, et al. Stroke 2005;36:1115-1119.