Transcript ATRIAL FIBRILLATION - Guildford GP Education

ATRIAL FIBRILLATION 2014
GP Update November 2014
Dr Philippa Howlett
Clinical 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 ratecontrol 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 selfmanagement of long-term anticoagulation on major clinical outcomes. Intern Med 2011; 154(7):472482
- 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 (SEARCHAF 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