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Modern Management in

Primary Care (AF1)

Dr Yassir Javaid

Primary Care Cardiovascular Lead

East Midlands Strategic Clinical Network

Dr Ravi Assomull

Consultant Cardiologist

London North West Healthcare NHS Trust

Setting the Scene…..

AF massively increases stroke risk

Increases stroke

risk by 340%

Increases stroke

risk by 240%

Increases stroke

risk by 430%

Increases stroke

risk by 480%

Gladstone DJ et al. Stroke. 2009; 40:235-240

Effect of first ischemic stroke in patients with AF (n=597)1

Stroke severity in patients with AF

% o

f p

a ti

e n

ts

Disabling Fatal

60%

40%

0%

50%

30%

20%

10%

70%

*The Copenhagen stroke study, a prospective community-based study. n=1,197

**In hospital mortality: 72 deaths, n=217with AF vs. 171 deaths n=968without AF †Discharge to own home: n=104with AF vs. 662 deaths n=968without AF ‡Length of hospital stay: 50.4 days with AF vs. 39.8 days without AF

Jorgensen, et al. Stroke 1996;27:1765-9

Among patients who had a stroke, those with AF experienced a:

increase in in-hospital mortality**

40% decrease in the relative chance of discharge to own home†

20% increase in the length of hospital stay‡

…compared to those without AF

AF Related Strokes Are More Severe

Stroke risk similar in persistent and

paroxysmal AF

The risk of stroke with asymptomatic or paroxysmal AF is comparable to that

with persistent AF

A n n u a l ri sk

o f

st ro

ke (

% )

Stroke risk category

Low Moderate High 0

2

4

6

8

10

12

14 Intermittent AF

Sustained AF

Journal of the American College of Cardiology volume 35, Issue 1, January 2000, Pages 183–187

http://www.sciencedirect.com/science/journal/07351097 http://www.sciencedirect.com/science/journal/07351097/35/1

• Do not offer aspirin monotherapy for AF related stroke prevention

NICE Guideline for AF (June 2014)

See NICE CG180 for full guideline https://www.nice.org.uk/guidance/cg180

Risks of a Fall While on Warfarin

• Absolute risk of subdural haematoma: 0.04%/yr

• Relative risk (RR) of subdural hematoma in someone who falls vs. someone who doesn’t: 1.4

• RR of subdural hematoma in faller on warfarin vs. faller not on warfarin: 3.3

So...

• Would need to fall 295 times a year to outweigh the benefits of warfarin (regardless of age/baseline stroke risk)

• Man-Son-Hing M, et al. Choosing antithrombotic therapy for elderly patients with atrial fibrillation who are at risk for falls. Arch Intern Med. 1999;159(7):677–685.

• Tinetti ME, Speechley M, Ginter SF. Risk Factors for Falls among Elderly Persons Living in the Community. N Engl J Med 1988; 319(26):1701-1707.

NICE Guideline for AF (June 2014)

• Do not withhold anticoagulation solely because of risk of having a fall

Stroke Prevention in AF….

NICE Guideline for AF (June 2014)

• CHA2DS2VASc for all patients: • Paroxysmal

• Persistent

• Permanent

• Atrial flutter

• Risk of recurrence after cardioversion back to sinus rhythm

• If CHA2DS2VASc ≥ 2 offer anticoagulation

• If CHA2DS2VASc = 1 consider anticoagulation

– “Offer” = confident that for the vast majority of pts an intervention

will do more good than harm and be cost-effective

– “Consider” = confident that for most pts an intervention will do more

good than harm and be cost-effective

Who should be anticoagulated? (ESC 2012)

Non-valvular AF Valvular AF*

ESC 2016 Recommendations

Eur Heart J doi:10.1093/eurheartj/ehw210.

• Anticoagulation may be with apixaban, dabigatran, rivaroxaban or a vitamin K antagonist

• Discuss the options for anticoagulation with each patient and base the choice on their clinical features and preferences

• If anticoagulation is not tolerated or contraindicated consider left atrial appendage occlusion (LAAO)

NICE Guideline for AF (June 2014)

Valvular vs non-valvular AF

Lip et Al Europace doi:10.1093/europace/euv309

The risk of ischaemic stroke "without" OAC exceeds the

risk of intracranial bleeding "with" OAC*

Relation between risk scores and annual event rates of ischaemic stroke and ICH in relation to use of oral anticoagulation in 159,013 Swedish AF patients followed up for 1.5±1.1 yrs (2005–2008)

CHA2DS2-VASc score

A n

n u

a l

e v e n

t ra

te

Score

0 1 2 3 4 5 6 7 8+

Stroke [no OAC]

Stroke [OAC]

ICH [OAC] ICH [no OAC]

0%

2%

4%

6%

8%

10%

12%

14%

16%

18% HAS-BLED score

A n

n u

a l

e v e n

t ra

te 0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

Score

0 1 2 3 4 5+

Stroke [no OAC]

Stroke [OAC]

ICH [OAC]

ICH [no OAC]

*Except those with a very low risk of stroke

Adapted from Friberg et al. Circulation 2012;125:2298–307.

HAS-BLED score

Letter Clinical characteristic Points awarded

H Hypertension (SBP > 160mmHg) 1

A Abnormal renal and liver function (1 point each) (Creat >200; Br >x2; ALP/AST>x3) 1 or 2

S Stroke 1

B Bleeding diathesis (Prev bleed/unexplained anaemia) 1

L Labile INRs 1

E Elderly (age >65 years) 1

D Drugs or alcohol (1 point each) (≥8 drinks/week) 1 or 2

Maximum 9 points

*This table is based on the likely risk / benefit of warfarin in NVAF patients. The NOACs have been shown to be at least non-inferior to warfarin in terms of reducing ischaemic stroke in NVAF

patients. Dabigatran 150mg has actually been shown to be superior to warfarin in reducing ischaemic stroke.

The NOACs have been shown to be not significantly more hazardous than warfarin in terms of causing major bleeds in NVAF patients. Dabigatran 110mg, apixaban 5mg and edoxaban 60mg

have actually been shown to be associated with significantly fewer major bleeds than warfarin.

Adapted from NICE: Patient Decision Aid – Atrial Fibrillation: medicines to help reduce your risk of a stroke – what are the options; June 2014

Cardiac rhythm assessment

• MANUAL pulse checking will give a strong clue to rhythm

– Now often ignored!

– Is it regular?

– Does the strength of pulse vary?

– What is the rate?

• ECG to monitor or confirm rhythm

SAFE Trial Fitzmaurice BMJ 2007(25 August) 335-383 • Objectives:

– Does screening improve detection of AF in primary care? – Opportunistic vs Systematic screening

• Design: – Multicentred Primary Care RCT across 50 practices in England

• Participants: – 14 802 patients ≥ 65 yrs in 25 intervention and 25 control practices

• Results: – Detection rate/year of new AF cases:

• 1.63% (screening practices) vs 1.04% (control practices) (difference 0.59%, 95% CI 0.20% to 0.98%).

• Systematic vs opportunistic screening detected similar numbers of new cases (1.62% v 1.64%, difference 0.02%, –0.5% to 0.5%).

Conclusion: Active screening significantly increases detection. The preferred method of screening in 10 care is opportunistic pulse taking with follow-up ECG

• Anticoagulation may be with apixaban, dabigatran, rivaroxaban or a vitamin K antagonist

• Discuss the options for anticoagulation with each patient and base the choice on their clinical features and preferences

• If anticoagulation is not tolerated or contraindicated consider left atrial appendage occlusion (LAAO)

NICE Guideline for AF (June 2014)

Limitations of warfarin

• Narrow therapeutic window

• Wide variation in metabolism

• Numerous food and drug interactions

• Need for regular coagulation monitoring and dose

adjustment

• Slow onset/offset

• Significant increase in intracranial and other

haemorrhage

Warfarin has a narrow therapeutic window

Based on Hylek EM, Singer DE. Risk factors for intracranial hemorrhage in outpatients taking warfarin. Ann Intern Med. 1994;120:897-902

Limitations of warfarin

• Narrow therapeutic window

• Wide variation in metabolism

• Numerous food and drug interactions

• Need for regular coagulation monitoring and dose

adjustment

• Slow onset/offset

• Significant increase in intracranial and other

haemorrhage

Vit K sensitive: VII, IX, X & PT

Apixaban

Rivaroxaban

Apixaban

Edoxaban

Dabigatran

Pivotal Warfarin Controlled Trials

Stroke Prevention in AF

6 Trials of Warfarin vs. Placebo

1989-1993

RE-LY