Atrial Fibrillation a simple pulse check to prevent a stroke

1. Atrial Fibrillation – a simple pulse check to prevent a stroke? Dr Kneale Metcalf

5. What is atrial fibrillation (AF)?

6. What happens in the heart?

7. ECG

8. Classification of AF

9. The Incidence of AF is Increasing in the United Kingdom In 1995, 0.9% of the United Kingdom population were affected by AF2 By 2006 this figure had risen to 1.3%1 The prevalence of AF will continue to rise as the proportion of elderly patients increases By 2050, it is estimated that AF will be present in 2% of the general population, and in a far higher proportion of elderly patients2 The Incidence of AF is Increasing in the United Kingdom In 1995, 0.9% of the United Kingdom population were affected by AF2 By 2006 this figure had risen to 1.3%1 The prevalence of AF will continue to rise as the proportion of elderly patients increases By 2050, it is estimated that AF will be present in 2% of the general population, and in a far higher proportion of elderly patients3 References: NICE Clinical Guideline 36 costing report. Available at: http://www.nice.org.uk/nicemedia/pdf/CG036costingreport.pdf. Accessed January 14, 2010 Stewart S, et al. Heart 2004; 90: 286–92 Savelieva I, et al. Europace 2008; 10: 647–65 The Incidence of AF is Increasing in the United Kingdom In 1995, 0.9% of the United Kingdom population were affected by AF2 By 2006 this figure had risen to 1.3%1 The prevalence of AF will continue to rise as the proportion of elderly patients increases By 2050, it is estimated that AF will be present in 2% of the general population, and in a far higher proportion of elderly patients3 References: NICE Clinical Guideline 36 costing report. Available at: http://www.nice.org.uk/nicemedia/pdf/CG036costingreport.pdf. Accessed January 14, 2010 Stewart S, et al. Heart 2004; 90: 286–92 Savelieva I, et al. Europace 2008; 10: 647–65

10. Other points about AF Can be symptomatic or asymptomatic If asymptomatic then how do you pick it up?

11. Core message Atrial fibrillation is common and getting commoner

12. AF and stroke

13. One sixth of all strokes are attributable to AF The Framingham Study examined the impact of atrial fibrillation (AF) on stroke incidence in 5,070 participants after 34 years of follow-up. Results of the study showed that the percentage of strokes attributable to AF increased dramatically with age.1 The investigators of the study concluded that AF is a major cause of stroke, particularly among elderly patients. Therefore, anticoagulation therapy should be a routine part of therapy for these patients. The Framingham Study examined the impact of atrial fibrillation (AF) on stroke incidence in 5,070 participants after 34 years of follow-up. Results of the study showed that the percentage of strokes attributable to AF increased dramatically with age.1 The investigators of the study concluded that AF is a major cause of stroke, particularly among elderly patients. Therefore, anticoagulation therapy should be a routine part of therapy for these patients.

14. AF is an Independent Risk Factor for Stroke AF patients have nearly a fivefold increased risk of stroke compared with patients without AF1 AF is an Independent Risk Factor for Stroke AF is well recognised as an important risk factor for stroke AF patients have a near fivefold increased risk of stroke1 and one in every six strokes occurs in a patient with AF2 Ischemic stroke associated with AF is typically more severe than stroke due to other aetiologies3 and stroke risk persists even in asymptomatic AF4 Incidence of stroke attributable to AF increases with age1 1.5% at age 50–59 years 23.5% at age 80–89 years This increase in stroke risk with age was statistically significant (p<0.01). Reference: 1. Wolf PA, et al. Stroke 1991; 22: 983–8 2. Fuster V, et al. Circulation 2006; 114: e257–354 3. Dulli DA, et al. Neuroepidemiology 2003; 22: 118–23 4. Page RL, et al. Circulation 2003; 107: 1141–5 AF is an Independent Risk Factor for Stroke AF is well recognised as an important risk factor for stroke AF patients have a near fivefold increased risk of stroke1 and one in every six strokes occurs in a patient with AF2 Ischemic stroke associated with AF is typically more severe than stroke due to other aetiologies3 and stroke risk persists even in asymptomatic AF4 Incidence of stroke attributable to AF increases with age1 1.5% at age 50–59 years 23.5% at age 80–89 years This increase in stroke risk with age was statistically significant (p<0.01). Reference: 1. Wolf PA, et al. Stroke 1991; 22: 983–8 2. Fuster V, et al. Circulation 2006; 114: e257–354 3. Dulli DA, et al. Neuroepidemiology 2003; 22: 118–23 4. Page RL, et al. Circulation 2003; 107: 1141–5

15. The Impact of AF on Stroke Outcomes Survival is poorer and stroke recurrence rates are higher following AF-related stroke The Impact of AF on Stroke Outcomes AF increases 30-day stroke-related mortality 25% of patients with AF-related stroke died versus 14% in non-AF strokes1 Ischaemic stroke associated with AF is almost twice as likely to be fatal compared with non-AF stroke1 Survival is poorer and stroke recurrence higher following AF-related stroke By 1 year, 63% AF patients versus 34% non-AF patients died By 1 year, stroke recurred in 23% AF patients versus 8% non-AF patients1 Reference: 1. Lin HJ, et al. Stroke 1996; 27 : 1760–4 The Impact of AF on Stroke Outcomes AF increases 30-day stroke-related mortality 25% of patients with AF-related stroke died versus 14% in non-AF strokes1 Ischaemic stroke associated with AF is almost twice as likely to be fatal compared with non-AF stroke1 Survival is poorer and stroke recurrence higher following AF-related stroke By 1 year, 63% AF patients versus 34% non-AF patients died By 1 year, stroke recurred in 23% AF patients versus 8% non-AF patients1 Reference: 1. Lin HJ, et al. Stroke 1996; 27 : 1760–4

16. The Impact of AF on Stroke Outcomes The Impact of AF on Stroke Outcomes Functional outcome is significantly poorer in patients with AF, and more patients remain bedridden The OR for a bedridden state following stroke due to AF was 2.23 (95% CI: 1.87, 2.59) Reference: Dulli DA, et al. Neuroepidemiology 2003; 22: 118–23The Impact of AF on Stroke Outcomes Functional outcome is significantly poorer in patients with AF, and more patients remain bedridden The OR for a bedridden state following stroke due to AF was 2.23 (95% CI: 1.87, 2.59) Reference: Dulli DA, et al. Neuroepidemiology 2003; 22: 118–23

17. Core message Atrial fibrillation causes stroke

18. Detecting AF

19. Detecting AF Pulse ECG 24hr ECG Fancy kit

20. AF – how can it be diagnosed? ECG (preferably 12-lead) Still the cornerstone of AF diagnosis

21. Opportunistic screening Taken up by 2 PBC Consortia this year in Norfolk during flu vaccination IDEAL setting High risk patients Nurse vaccination Done to protocol GP paid! Evidence of effectivness N Essex screened 30000 in 6 weeks 361 patients newly diagnosed with AF

22. Protocol Patients aged over 65 years, who have no record of AF, will have their pulse checked for at least 30 seconds to look for irregularity. If irregularity is identified, then they will be followed up with: • resting 12-lead ECG • blood tests for lipid profile, renal function, fasting glucose, full blood count, thyroid function • body mass index • urinalysis • clinical assessment of cardiovascular system • overall evaluation of cardiovascular risk Management options will include: • warfarin (or antiplatelet agents if warfarin contraindicated) • pulse rate control • consideration of referral for cardioversion.

23. 24 hr ECG (and longer) As AF can be paroxysmal then one off pulse or ECG may miss! 24 hr ECG may have a better pick up

24. Effectiveness of different rhythm detectors

25. CARDIST Trial Patients with stroke or TIA No Hx AF 24 hr ECG, 7 day automated device, wrist watch device Comparing AF pick up rate

26. Core message AF can be detected by a simple pulse check

27. Managing AF Blood thinning Antiplatelets Anticoagulation Rhythm control Rate Stabalisation Operations

28. The CHADS2 Scoring System CHADS2 is a points-based system for predicting risk of stroke in AF based on key risk factors1 Congestive heart failure 1 point Hypertension 1 point Age >75 years 1 point Diabetes mellitus 1 point Stroke or TIA 2 points The CHADS2 Scoring System Irrespective of clinical subtype of atrial fibrillation, appropriate anti-thrombotic treatment is mandatory, based on risk factors for stroke and thromboembolism1 CHADS2 is a points-based system for predicting risk of stroke in AF based on key risk factors2 The greater the number of points, the greater the risk and the greater the need for anti-thrombotic therapy AF patients with zero points are recommended to take aspirin, patients with one point require anti-platelet or anti-coagulant therapy and patients with two or more points are recommended to receive an oral vitamin K antagonist, such as warfarin References 1. NICE Clinical Guideline 36. Available at: www.nice.org.uk/CG036 2. Gage BF, et al. JAMA 2001; 285: 2864–70The CHADS2 Scoring System Irrespective of clinical subtype of atrial fibrillation, appropriate anti-thrombotic treatment is mandatory, based on risk factors for stroke and thromboembolism1 CHADS2 is a points-based system for predicting risk of stroke in AF based on key risk factors2 The greater the number of points, the greater the risk and the greater the need for anti-thrombotic therapy AF patients with zero points are recommended to take aspirin, patients with one point require anti-platelet or anti-coagulant therapy and patients with two or more points are recommended to receive an oral vitamin K antagonist, such as warfarin References 1. NICE Clinical Guideline 36. Available at: www.nice.org.uk/CG036 2. Gage BF, et al. JAMA 2001; 285: 2864–70

29. Aspirin

30. Warfarin

31. RE-LY Trial (Dabigatran) Dabigatran Direct thrombin inhibitor NON MONITORED ANTICOAGULATION 18000 patients, compared to warfarin 150mg better than warfarin (RRR 34%)

32. Rate / rhythm control Beta blockers Amiodarone Flecainide Digoxin Etc. New antiarrhythmic agent Dronederone Cleaner amiodarone Trial = ATHENA 4628 patients (PAF) 24% RRR of hospitalisation or death from any cause

33. Operations RF ablations

34. Core message Treatment is effective

35. Summary A simple pulse check can prevent a stroke!