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AF: Management and Stroke Prevention
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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
* 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: 2893-962. 2. Kirchhof P et al. Europace 2014; 16: 6-14.
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
AF associated with rheumatic heart disease and mechanical valves
require vitamin K antagonists
References: 1. Kirchhof P et al. Eur Heart J 2016; 37: 2893-962. 2. January CT et al. Circulation 2014; 130: 2071-104.
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
Risk Factors for Atrial Fibrillation Include:
•
•
•
•
•
•
Older age
Hypertension
Diabetes mellitus
Myocardial infarction
Heart failure
Chronic kidney disease
Reference: 1. Kirchhof P et al. Eur Heart J 2016; 37: 2893-962.
•
•
•
•
•
•
•
Obesity
Obstructive sleep apnoea
Cardiothoracic surgery
Smoking
Intense exercise
Alcohol use
Hyperthyroidism
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
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
References: 1. Kirchhof P et al. Eur Heart J 2016; 37: 2893-962. 2. NICE Clinical Guideline. 2014. www.nice.org.uk/guidance/cg180.
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
AF Management
References: 1. Kirchhof P et al. Eur Heart J 2016; 37: 2893-962. 2. NICE Clinical Guideline. 2014. www.nice.org.uk/guidance/cg180.
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
References: 1. Kirchhof P et al. Eur Heart J 2016; 37: 2893-962. 2. Friberg L et al. Stroke 2014; 45: 2599-605.
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 Clinical Guideline. 2014. www.nice.org.uk/guidance/cg180.
Anticoagulants to Prevent Stroke
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
References: 1. Amerena JV et al. Med J Aust 2013; 199: 592-7. 2. Kirchhof P et al. Eur Heart J 2016; 37: 2893-962.
.
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
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: 860-5. 2. Kirchhof P et al. Eur Heart J 2016; 37: 2893-962.
CHA2DS2-VASc to Assess Stroke Risk1
Risk Factor
Score
C ongestive heart failure/LV dysfunction
H ypertension
A ge ≥ 75 years
D iabetes mellitus
S troke/TIA/TE
1
1
2
1
2
V ascular disease (prior myocardial infarction, peripheral artery
disease, or aortic plaque)
A ge 6574 y
S ex category (ie female gender)
1
1
1
Reference: 1. Lip GY et al. Chest 2010; 137: 263-72.
Calculate Mr M’s CHA2DS2-VASc Score
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
Parameter
Score
Congestive Heart Failure/LVD?
0
Hypertension?
+1
Age 6574 years
+1
Age ≥75 years
0
Diabetes?
0
Stroke, TIA or thromboembolism?
0
Vascular disease?
0
Female gender?
0
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
References: 1. Kirchhof P et al. Eur Heart J 2016; 37: 2893-962. 2. Lane DA et al. Circulation 2012; 126: 860-5.
Strategies to Minimise Bleeding Risk*
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Determine bleeding history1,2
Check for anaemia2
†
1,3
Consider use of PPI in patients with history of GI bleeding or ulcers
Ensure good blood pressure control1,2
Avoid medications that increase bleeding risk, e.g. NSAIDs1,2
Patient education:2,4
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Adherence to medication
Avoid excessive alcohol consumption
Awareness of risks for minor bleeds
Signs and symptoms of GI bleed
* 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: 1467-507. 2. Kirchhof P et al. Eur Heart J 2016; 37: 2893-962. 3. Agewall S et al.
Eur Heart J 2013; 34: 1708-13, 13a-13b. 4. Abraham NS. Am J Gastroenterol Suppl 2016; 3: 2-12.
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
Reference: 1. Heidbuchel H et al. Europace 2015; 17: 1467-507.
.
Controlling Arrhythmia
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
References: 1. January CT et al. Circulation 2014; 130: 2071-104. 2. Kirchhof P et al. Eur Heart J 2016; 37: 2893-962. 3. Lavergne F et al.
J Thorac Dis 2015; 7: E575-84. 4. NICE Clinical Guideline. 2014. www.nice.org.uk/guidance/cg180.
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
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: 2893-962. 2. Amerena JV et al. Med J Aust 2013; 199: 592-7.
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 et al. Eur Heart J 2016; 37: 2893-962. 2. NICE Clinical Guideline. 2014. www.nice.org.uk/guidance/cg180.
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
– beta-blocker
– diltiazem
– digoxin
• A target resting heart rate <110 bpm is reasonable if patients remain
asymptomatic and left ventricular systolic function is preserved2,3
References: 1. January CT et al. Circulation 2014; 130: 2071-104. 2. NICE Clinical Guideline. 2014. www.nice.org.uk/guidance/cg180. 3.
Kirchhoff P, Benussi S, Kotecha D et al. Eur Heart J.2016; 37 2893–962.
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 et al. Eur Heart J 2016; 37: 2893-962. 2. Amerena JV et al. Med J Aust 2013; 199: 592-7.
Summary
• 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?
Summary
Integrated Management of Patients with AF
Reference: 1. Kirchhof P et al. Eur Heart J 2016; 37: 2893-962.
Q&A
Presentation end