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 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

Ruff et al

NICE GUIDELINES – CHA 2 DS 2 -VASc Use the CHA 2 DS 2 -VASc risk score and HAS-BLED scores to estimated TE and bleeding risk Consider OAC in those with CHA 2 DS 2 VASc = 1 Offer OAC to those with CHA 2 DS 2 VASc ≥ 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 rate- control 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

REFERENCES - Bloomfield HE, Krause A, Greer N, et al. Meta-analysis: effect of patient self-testing and self- management of long-term anticoagulation on major clinical outcomes. Intern Med 2011; 154(7): 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: 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):e 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): Cooke, G., Doust, J. Is pulse palpation helpful in detecting atrial fibrillation? A systematic review. Journal of Family Practice 2006;55(2): 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): Harper P, Harper J, Hill C. An audit of anticoagulation management to assess anticoagulant control using decision support software. BMJ Open 2014; 4: e 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: Lin HJ, Wolf PA, Kelly-Hayes M, et al. Stroke Severity in Atrial Fibrillation – The Framingham Study. Stroke 1996; 27:

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): 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 (SEARCH- AF stroke prevention study): a cross-sectional study protocol. BMJ Open 2012; 2:e doi: /bmjopen 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): 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): 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): Samol A, Masin M, Gellner R, et al. Prevalence of unknown atrial fibrillation in patients with risk factors. Europace 2013; 15(5): 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