2. ELIQUIS_PPT_Template_V1jz
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3. AF: Management and Stroke Prevention

4. Disclaimer
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5. AF: Range of Presentations1
Asymptomatic or minimal symptoms (25–40%)
Symptoms felt do not correlate well with episodes of AF and patients can have symptomatic and silent episodes over time
Severe or disabling symptoms (15–30%)*
Chronic, paroxysmal
Chronic, persistent
Acute, haemodynamically unstable
Speaker notes
It is important to establish the pattern of AF as it is a heterogeneous condition and can have many different presentations.
Reference
Kirchhof P, Benussi S, Kotecha D et al ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:
Kirchhof P, Ammentorp B, Darius H et al. Management of atrial fibrillation in seven European countries after the publication of the 2010 ESC Guidelines on atrial fibrillation: primary results of the PREvention oF thromboemolic events--European Registry in Atrial Fibrillation (PREFER in AF). Europace 2014; 16: 6-14
* Maximum symptom score of intermediate or frequent for palpitations, fatigue, dizziness, dyspnea, chest pain, anxiety.2
Reference: 1. Kirchhof P et al. Eur Heart J 2016; 37: Kirchhof P et al. Europace 2014; 16: 6-14.

6. Types and Patterns of Atrial Fibrillation1,2
NonValvular AF
AF in the absence of rheumatic mitral stenosis or a mechanical prosthetic heart valve
Paroxysmal AF
AF that terminates spontaneously usually within 48 hours, may continue for up to 7 days
Episodes may recur with variable frequency
Persistent AF
Continuous AF that is sustained for longer than 7 days
Long-standing persistent AF
Continuous AF > 12 months in duration
Speaker notes
This is the widely accepted terminology for the different of types and patterns of AF.
In the recent ESO guidelines it is stated:
"Traditionally, patients with AF have been dichotomized into ‘valvular’ and ‘non-valvular’ AF. Although slightly different definitions have been used, valvular AF mainly refers to AF patients that have either rheumatic valvular disease (predominantly mitral stenosis) or mechanical heart valves. In fact, while AF implies an incremental risk for thromboembolism in patients with mitral valve stenosis, there is no clear evidence that other valvular diseases, including mitral regurgitation or aortic valve disease, need to be considered when choosing an anticoagulant or indeed to estimate stroke risk in AF. Therefore, we have decided to replace the historic term ‘non-valvular’ AF with reference to the specific underlying conditions.”
In terms of anticoagulation, AF associated with rheumatic heart disease and mechanical valves require vitamin K antagonists.
References
1. Kirchhof P, Benussi S, Kotecha D et al ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:
2. January CT, Wann LS, Alpert JS et al AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation 2014; 130:
AF associated with rheumatic heart disease and mechanical valves require vitamin K antagonists
References: 1. Kirchhof P et al. Eur Heart J 2016; 37: January CT et al. Circulation 2014; 130:

7. Mr M
Aged 67 years Non-smoker, minimal alcohol intake Taking lisinopril 20 mg/day for hypertension Dyslipidaemia treated with statin BMI 30 kg/m2, waist circumference 91 cm
Visits reporting general fatigue and that he has noticed occasional feelings of ‘palpitations’ in his chest and dizziness

8. Risk Factors for Atrial Fibrillation Include:
Older age
Hypertension
Diabetes mellitus
Myocardial infarction
Heart failure
Chronic kidney disease
Obesity
Obstructive sleep apnoea
Cardiothoracic surgery
Smoking
Intense exercise
Alcohol use
Hyperthyroidism
Speaker notes
Mr M is overweight, has hypertension and the presence of sleep apnoea is likely, and so he is at risk for atrial fibrillation.
Reference
1. Kirchhof P, Benussi S, Kotecha D et al ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:
Reference: 1. Kirchhof P et al. Eur Heart J 2016; 37:

9. Mr M: Atrial Fibrillation?
Further History:
When asked about sleep, he reports that his wife complains about his loud snoring
No chest pain, dyspnoea, peripheral oedema or syncope
Examination:
Heart rate 74 BPM and pulse regular
Blood pressure 166/100 mmHg
Respiration rate 16 breaths per minute, lung sounds normal
Speaker notes
Mr M may have atrial fibrillation.
A complete medical history is needed, and a clinical evaluation that includes assessment for concomitant conditions. Initial blood tests should evaluate thyroid and kidney function, as well as serum electrolytes and full blood count.

10. Detecting AF Irregular pulse felt on manual palpation1,2
Confirmed by ECG: irregular R-R intervals, no P waves1
An episode lasting at least 30 seconds is diagnostic for AF1
Detecting paroxysmal AF usual requires:2
24-hour ambulatory ECG monitoring
Event recorder ECG for symptomatic episodes more than 24 hours apart
Speaker notes
An ECG is recommended to establish a suspected diagnosis of AF, to determine rate in AF, and to screen for conduction defects, ischaemia, and signs of structural heart disease. Intermittent monitoring techniques are needed to identify paroxysmal AF.
Please expand further on the detection of paroxysmal AF as this is a particular issue of concern in primary care.
References
1. Kirchhof P, Benussi S, Kotecha D et al ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:
2. NICE Guidelines. Atrial fibrillation: management Available from [Accessed December 2016].
References: 1. Kirchhof P et al. Eur Heart J 2016; 37: NICE Clinical Guideline

11. Mr M: Atrial Fibrillation?
Test results:
24 hour ECG shows episodes of AF, no other cardiac abnormalities found
Tests including complete blood count, electrolytes, HbA1c, thyroid and liver function were within normal limits
Speaker notes
As Mr M has a regular pulse, 24 hour ambulatory ECG monitoring or an event recorder may be needed to detect paroxysmal AF.

12. AF Management Speaker notes
Haemodynamic unstable cases require urgent referral. For other presentations of AF, management in primary care may be appropriate – please briefly outline the type of cases that may require referral and those that can be managed by the general practitioner.
References
1. Kirchhof P, Benussi S, Kotecha D et al ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:
2. NICE Guidelines. Atrial fibrillation: management Available from [Accessed December 2016].
References: 1. Kirchhof P et al. Eur Heart J 2016; 37: NICE Clinical Guideline

13. Aims of Management Prevent stroke1
Up to a third of ischaemic strokes are due to AF2
Anticoagulants significantly reduce the risk of stroke due to AF1
Control arrhythmia; rate control, or rhythm control if symptoms remain1
Improve quality of life1
Symptomatic patients can experience limiting lethargy, palpitations, dyspnoea, chest tightness, sleeping difficulties, and psychosocial distress
Speaker notes
Largest most recent stroke study confirmed that 33% of strokes are due to AF at the time of the stroke. In 24% AF was known, but only 4% were on anticoagulant,
12% were on aspirin which doesn’t work, and 8% on no antithrombotic. That is 20% of all strokes could be prevented if we could change habits to increase anticoagulant prescription. In Sweden they are attempting this as part of screening (StrokeStop study), to find actionable AF.
Reduction of symptoms by either rate or rhythm control when required is also part of AF management.
References
1. Kirchhof P, Benussi S, Kotecha D et al ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:
2. Friberg L, Rosenqvist M, Lindgren A et al. High prevalence of atrial fibrillation among patients with ischemic stroke. Stroke 2014; 45:
References: 1. Kirchhof P et al. Eur Heart J 2016; 37: Friberg L et al. Stroke 2014; 45:

14. Management of AF Should Include:1
Awareness of symptoms of stroke /TIA
Lifestyle changes to reduce stroke risk
Psychological support if needed
Comprehensive education and information on:
cause, effects and possible complications of atrial fibrillation
anticoagulation and bleeding risks
management of rate and rhythm and what to expect
Reference
1. NICE Guidelines. Atrial fibrillation: management Available from [Accessed December 2016].
Reference: 1. NICE Clinical Guideline

15. Anticoagulants to Prevent Stroke

16. Anticoagulants to Prevent Stroke
Anticoagulation should be initiated early in all suitable patients regardless of AF pattern or symptoms1,2
Specialist referral not needed for anticoagulation in uncomplicated patients2
Evidence supporting antiplatelet monotherapy for stroke prevention in AF is limited2
The prescription of anticoagulation should be based on stroke risk assessed using the CHA2DS2-VASc scoring system1,2
Speaker notes
All cases not requiring urgent referral should be assessed for stroke risk and anticoagulation prescribed for those at risk.
References
1. Amerena JV, Walters TE, Mirzaee S et al. Update on the management of atrial fibrillation. Med J Aust 2013; 199:
2. Kirchhof P, Benussi S, Kotecha D et al ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:
References: 1. Amerena JV et al. Med J Aust 2013; 199: Kirchhof P et al. Eur Heart J 2016; 37: .

17. Aim is to Identify Who Does NOT Need Anticoagulation
Stroke risk in AF is a continuum1
The aim of risk assessment is to identify truly low-risk patients who do not need any antithrombotic therapy1
Patients with stroke risk factors should be considered for oral anticoagulation therapy1,2
Unlike most risk assessment questionnaires, this scoring system identifies those who do not require oral anticoagulant treatment. Patients with stroke risk factors will benefit from treatment.
References
1. Lane DA, Lip GY. Use of the CHA(2)DS(2)-VASc and HAS-BLED scores to aid decision making for thromboprophylaxis in nonvalvular atrial fibrillation. Circulation 2012; 126:
2. Kirchhof P, Benussi S, Kotecha D et al ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:
Understanding this paradigm shift in risk assessment is important to reduce the underuse of anticoagulant treatment that occurs despite evidence of efficacy in reducing stroke risk1,2
References: 1. Lane DA et al. Circulation 2012; 126: Kirchhof P et al. Eur Heart J 2016; 37:

18. CHA2DS2-VASc to Assess Stroke Risk1
Risk Factor Score
C ongestive heart failure/LV dysfunction 1
H ypertension 1
A ge ≥ 75 years 2
D iabetes mellitus 1
S troke/TIA/TE 2
V ascular disease (prior myocardial infarction, peripheral artery disease, or aortic plaque) 1
A ge 6574 y 1
S ex category (ie female gender) 1
Reference
1. Lip GY, Nieuwlaat R, Pisters R et al. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest 2010; 137:
Reference: 1. Lip GY et al. Chest 2010; 137:

19. Calculate Mr M’s CHA2DS2-VASc Score
Aged 67 years
Non-smoker, minimal alcohol intake
Taking lisinopril 20 mg/day for hypertension
Dyslipidaemia treated with statin
BMI 30 kg/m2, waist circumference 91 cm
Parameter
Score
Congestive Heart Failure/LVD?
Hypertension? +1
Age 6574 years
Age ≥75 years
Diabetes?
Stroke, TIA or thromboembolism?
Vascular disease?
Female gender?

20. Acting on CHA2DS2-VASc Score1,2
CHA2DS2-VASc score of 0: recommendation is no antithrombotic therapy1,2
Consider anticoagulation in women if CHA2DS2-VASc score = 2. Anticoagulation recommended if CHA2DS2-VASc score ≥ 3
Consider anticoagulation in men if CHA2DS2-VASc score = 1. Anticoagulation recommended if CHA2DS2-VASc ≥ 21,2
The new guidelines make differences in recommendations between men and women a little complicated and it is unclear whether there is agreement on the differences especially in Australia.
References
1. Kirchhof P, Benussi S, Kotecha D et al ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:
2. Lane DA, Lip GY. Use of the CHA(2)DS(2)-VASc and HAS-BLED scores to aid decision making for thromboprophylaxis in nonvalvular atrial fibrillation. Circulation 2012; 126:
3. Camm AJ, Lip GY, De Caterina R et al focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation--developed with the special contribution of the European Heart Rhythm Association. Europace 2012; 14:
References: 1. Kirchhof P et al. Eur Heart J 2016; 37: Lane DA et al. Circulation 2012; 126:

21. Strategies to Minimise Bleeding Risk*
Determine bleeding history1,2
Check for anaemia2
Consider use of PPI in patients with history of GI bleeding or ulcers1,3†
Ensure good blood pressure control1,2
Avoid medications that increase bleeding risk, e.g. NSAIDs1,2
Patient education:2,4
Adherence to medication
Avoid excessive alcohol consumption
Awareness of risks for minor bleeds
Signs and symptoms of GI bleed
Speaker notes
It is important to note that the high stroke risk without anticoagulation usually exceeds the bleeding risk on an anticoagulant, even in the elderly.
Uncontrolled high blood pressure increases the risk of stroke and of bleeding events. It can also lead to recurrent AF. Therefore, good blood pressure control is important in the management of AF patients.
References
1. Heidbuchel H, Verhamme P, Alings M et al. Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace 2015; 17:
2. Kirchhof P, Benussi S, Kotecha D et al ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:
3. Agewall S, Cattaneo M, Collet JP et al. Expert position paper on the use of proton pump inhibitors in patients with cardiovascular disease and antithrombotic therapy. Eur Heart J 2013; 34: , 13a-13b.
4. Abraham NS. Prevention of Gastrointestinal Bleeding in Patients Receiving Direct Oral Anticoagulants. Am J Gastroenterol Suppl 2016; 3: 2-12.
* Stroke and bleeding risk factors overlap, however a high bleeding risk should generally not result in withholding anticoagulation2
† PPIs may accelerate the absorption of warfarin and may reduce dabigatran exposure. PPIs are unlikely to influence the pharmacokinetics of factor Xa inhibitors.3
References: 1. Heidbuchel H et al. Europace 2015; 17: Kirchhof P et al. Eur Heart J 2016; 37: Agewall S et al. Eur Heart J 2013; 34: , 13a-13b. 4. Abraham NS. Am J Gastroenterol Suppl 2016; 3: 2-12.

22. Minor Bleeding
Minor bleeding, usually classified as ‘nuisance bleeding’, can occur with anticoagulant use:
Bleeds are usually temporary
Does not usually require anticoagulant discontinuation or dose adjustment
Is not predictive of major bleeding risk
If required can consider preventive interventions, e.g.:
Cauterisation of the intranasal arteries
Haemorrhoidectomy
Speaker notes
Patients may need to be educated on how to avoid nuisance bleeds, and the value of anticoagulation in preventing stroke to prevent discontinuation.
Reference
1. Heidbuchel H, Verhamme P, Alings M et al. Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular
Reference: 1. Heidbuchel H et al. Europace 2015; 17: .

23. Controlling Arrhythmia

24. Address any Reversible Precipitating Causes1
Weight loss in obese patients reduces AF episodes and symptoms2
Obesity may also be a risk factor for ischaemic stroke, thrombo-embolism, and death in AF patients2
AF is associated with obstructive sleep apnoea2
Treatment of obstructive sleep apnoea reduces the recurrence of AF3
Lifestyle factors2
Smoking, alcohol and caffeine intake can precipitate AF4
Speaker notes
Chronic AF can be improved by addressing precipitating causes and these should be addressed before starting rate or rhythm control.
References
1. January CT, Wann LS, Alpert JS et al AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation 2014; 130:
2. Kirchhof P, Benussi S, Kotecha D et al ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:
3. Lavergne F, Morin L, Armitstead J et al. Atrial fibrillation and sleep-disordered breathing. J Thorac Dis 2015; 7: E
4. NICE Guidelines. Atrial fibrillation: management Available from [Accessed December 2016].
References: 1. January CT et al. Circulation 2014; 130: Kirchhof P et al. Eur Heart J 2016; 37: Lavergne F et al. J Thorac Dis 2015; 7: E NICE Clinical Guideline

25. Rate or Rhythm Control Rate control and rhythm control:1
can both improve AF-related symptoms
may preserve cardiac function, but neither have demonstrated a reduction in long-term morbidity or mortality
Selecting between these approaches depends on patient characteristics and preference e.g.:2
References
1. Kirchhof P, Benussi S, Kotecha D et al ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:
2. Amerena JV, Walters TE, Mirzaee S et al. Update on the management of atrial fibrillation. Med J Aust 2013; 199:
Rate control
Rhythm control
Advanced age
Younger age
Longstanding persistent AF
More frequent episodes with severe symptoms
References: 1. Kirchhof P et al. Eur Heart J 2016; 37: Amerena JV et al. Med J Aust 2013; 199:

26. Rate Control
Rate control is an integral part of the management of AF patients, and is often sufficient to improve AF-related symptoms1
Rate control should be considered as a first‑line strategy except:2
Where there is a reversible cause
In heart failure caused by atrial fibrillation
In new‑onset atrial fibrillation
If atrial flutter is present that may require an ablation strategy to restore sinus rhythm
References
1. Kirchhof P, Benussi S, Kotecha D et al ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:
2. NICE Guidelines. Atrial fibrillation: management Available from [Accessed December 2016].
References: 1. Kirchhof P et al. Eur Heart J 2016; 37: NICE Clinical Guideline

27. Treatment for Rate Control1,2
Initial monotherapy:1,2
beta‑blocker
nondihydropyridine calcium‑channel blocker (e.g. verapamil, diltiazem)
If monotherapy does not control symptoms, combination therapy with any 2 of the following:1,2
diltiazem
digoxin
A target resting heart rate <110 bpm is reasonable if patients remain asymptomatic and left ventricular systolic function is preserved2,3
Speaker notes
Amiodarone should not be offered for long-term rate control (NICE)
References
1. January CT, Wann LS, Alpert JS et al AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation 2014; 130:
2. NICE Guidelines. Atrial fibrillation: management Available from [Accessed December 2016]. 3. Kirchhof P, Benussi S, Kotecha D et al ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:
References: 1. January CT et al. Circulation 2014; 130: NICE Clinical Guideline Kirchhoff P, Benussi S, Kotecha D et al. Eur Heart J.2016; –962.

28. Rhythm Control1,2
Pharmacological and/or electrical options are available if rhythm control is required to restore sinus rhythm and reduce symptoms
Referral to a cardiologist may be required to determine the optimal approach to rhythm control for the patient
References
1. Kirchhof P, Benussi S, Kotecha D et al ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:
2. Amerena JV, Walters TE, Mirzaee S et al. Update on the management of atrial fibrillation. Med J Aust 2013; 199:
References: 1. Kirchhof P et al. Eur Heart J 2016; 37: Amerena JV et al. Med J Aust 2013; 199:

29. Summary Discussion among tables
The different risk factors, aetiologies and presentations of AF that determine management
Stroke prevention and rate or rhythm control are the main approaches to management in stable patients
Discussion among tables
What would you now do for Mr M regarding his ongoing management?
Moderator: Please give participants a couple of minutes to discuss among themselves what they would do next with Mr M.

30. Summary Integrated Management of Patients with AF
Reference
1. Kirchhof P, Benussi S, Kotecha D et al ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:
Reference: 1. Kirchhof P et al. Eur Heart J 2016; 37:

31. Presentation end