Atrial Fibrillation Now and Then Min-Yen Han,M.D. November 15,2014

AF is a common cardiac rhythm disturbance and increases in prevalence with advancing age Affecting between 2.7 million and 6.1million American adults and by 2050 the number will be 5.6 to 12.1million AF is associated with a 5 fold increased risk of stroke,which is likely to be more severe than non-AF related stroke.

AF is also associated with a 3-fold risk of HF and a 2-fold increased risk of both demantia and mortality It is estimated that treating patients with AF adds $26 billion to the U.S. healthcare bill annually

AF symptoms range from non-existent to severe,symptoms including fatigue,palpitation Dyspnea,hypotension,syncope or HF. AF classification: Paroxysmal: AF that terminates spontaneuosly or with intervention within 7 days of onset Persistent: Continous AF that is sustained more than 7 days Longstanding persistent: Continous AF of more than 12 months Permanet AF Nonvalcular AF:AF is the absence of rheumatic mitral stenosis,a machanical or bioprostheric heart valse or mitral valve repair.

Goals of medical management of AF: Rate control Rhythm control Prevention of thromboembolic events

Anticoagulation in AF Prior to Oct.2010 Warfarin was the only antigoagulant then New NOVAL anticoagulants after Oct.2010 Dabigatran,an direct thrombin inhibitor Rivaroxaban,,Apixaban and Edoxaban,factor X inhibitor

Advantage and disanvantage of the old and the new antigoagulants

Tools for Assessing Stroke Risk: CHADS2 Score CHADS2-VASc Score Risk Factor Score Risk Factor Score CHF 1 CHF(LV Dys.) 1 Hypertension 1 Hypertension 1 Age >75 Y 1 Age >75 1 Diabetes 1 Diabetes 1 Stroke or TIA Hx 2 Stroke/TIA/TE 2 Maximal 6 Vascular diseae 1 Age Female 1 Maximal 9

Tools for Assesssing Bleeding Risk: HAS-BLED Score Risk Factor Score Hypertension SBP>160mmHg 1 Abnormal renal or liver function(each) 1 Stroke 1 Bleeding hx or predisposition 1 Labile INR 1 Elderly age>65y 1 Drugs or alcohol Antiplatelets or NSAIDs 1 Alcohol use >8 servings/wk 1 Maximal 9

2014 AHA/ACC/HRS AF Guidelines: NVAF Stroke risk assessment using CHA2DS2-VASc Share decision making:risk factors,cost, Tolerability,patient preference,drug interaction potential, HAS-BLED score Not recommended for bleed risk assessment

CHA2DS2-VASc Score Recommended >2 Warfarin(INR2-3), Apixaban,Dabigatran, Rivaroxaban 1 Same as above or Aspirin or No antithrombotic Rx 0 No antithrombotic Rx