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Overview. Atrial fibrillationStroke and atrial fibrillation Detecting atrial fibrillationManaging atrial fibrillation. What is atrial fibrillation (AF)?.
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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: 28692
Savelieva I, et al. Europace 2008; 10: 64765
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: 28692
Savelieva I, et al. Europace 2008; 10: 64765
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 5059 years
23.5% at age 8089 years
This increase in stroke risk with age was statistically significant (p<0.01).
Reference:
1. Wolf PA, et al. Stroke 1991; 22: 9838
2. Fuster V, et al. Circulation 2006; 114: e257354
3. Dulli DA, et al. Neuroepidemiology 2003; 22: 11823
4. Page RL, et al. Circulation 2003; 107: 11415
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 5059 years
23.5% at age 8089 years
This increase in stroke risk with age was statistically significant (p<0.01).
Reference:
1. Wolf PA, et al. Stroke 1991; 22: 9838
2. Fuster V, et al. Circulation 2006; 114: e257354
3. Dulli DA, et al. Neuroepidemiology 2003; 22: 11823
4. Page RL, et al. Circulation 2003; 107: 11415
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 : 17604
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 : 17604
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: 11823The 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: 11823
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: 286470The 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: 286470
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!