Evolving Trends in Atrial Fibrillation Management and Stroke Risk Reduction

Evolving Trends in Atrial Fibrillation Management and Stroke Risk Reduction

Emerging Challenges in Primary Care: Update 2013 1

Faculty •  Jan Basile, MD −  Professor of Medicine, Seinsheimer Cardiovascular Health Program, Division of General Internal Medicine, Medical University of South Carolina, Ralph H. Johnson VA Medical Center, Charleston, SC •  Keith C. Ferdinand MD, FACC, FAHA -  Chair, National Forum for Heart Disease and Stroke Prevention, Professor of Clinical Medicine, Tulane University School of Medicine, Tulane Heart and Vascular Institute, New Orleans, LA •  Valerian L. Fernandes, MD, MRCP, FACC -  Associate Professor of Medicine, Medical University of South Carolina, DirectorCardiac Catheterization Laboratories, Ralph H. Johnson VA Medical Center, Charleston, SC •  Louis Kuritzky, MD −  Clinical Assistant Professor, Department of Community Health & Family Medicine, University of Florida, Gainesville, FL

NACE - Emerging Challenges in Primary Care: 2013

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Atrial Fibrillation - 1

Evolving Trends in Atrial Fibrillation Management and Stroke Risk Reduction

Faculty Disclosure •  Jan Basile, MD −  Speaker – Boehringer Ingelheim, Daiichi Sankyo, Forest Labs, Takeda −  Consultant - Forest Labs, Takeda •  Keith C. Ferdinand MD, FACC, FAHA -  Consultant – Takeda, Novartis, Forest, Daiichi Sankyo -  Speaker – AstraZeneca, Takeda •  Valerian L. Fernandes, MD, MRCP, FACC -  Spouse is a Consultant for Ipsen •  Louis Kuritzky, MD −  Nothing to disclose

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Learning Objectives •  Use the CHADS2 Score to Risk Stratify AF patients •  Choose appropriate pharmacologic Rx for AF patients •  Recognize the role of catheter ablation in AF patients •  Effectively manage antithrombotic therapy in the perioperative setting 4

NACE - Emerging Challenges in Primary Care: 2013

Atrial Fibrillation - 2

Evolving Trends in Atrial Fibrillation Management and Stroke Risk Reduction

ARS #1 Clinical Scenario: Steve E. Steve E, a 79 y/o hispanic male with a history of HTN and a left hemispheric stroke 2 years ago, was asymptomatic until 2 days ago when he developed intermittent palpitations and presented to your office. EKG: AF at 120 bpm. Steve’s CHADS2 score is:

1)  2)  3)  4)  5) 

1 2 4 6 Not sure

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ARS # 2 A 62 year dermatologist has recently been diagnosed with AF. He has hypertension and type 2 diabetes, both of which are well controlled. Being a physician, he asks "I've read about all the treatments; which is the best treatment for my AF?" You should answer

1) All of the newer agents are statistically superior to warfarin for stroke risk reduction 2) The major reason to provide warfarin is because overall costs with warfarin are much less than other agents 3) In the absence of head-to-head trials, it is not possible to know if any one of the newer agents is superior to another 4) Major bleeding risk with newer agents is markedly less than with warfarin

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NACE - Emerging Challenges in Primary Care: 2013

Atrial Fibrillation - 3

Evolving Trends in Atrial Fibrillation Management and Stroke Risk Reduction

ARS #3 Perioperative Management of Tomas, a 62 Y.O. with AF, HTN, DM Tomas is undergoing CV surgery. His INR has been in the therapeutic range about 75% of the time on warfarin 5 mg/d. What should be done about his warfarin dose perioperatively? 1)  Continue 5 mg/d without interruption 2)  Discontinue warfarin 3 days preop, resume 12-24 hrs after adequate hemostasis 3)  Discontinue 5 days preop, resume 12-24 hrs after adequate hemostasis 4)  Switch to clopidogrel 75 mg/d 3 days preop, then resume warfarin 12-24 hrs after adequate hemostasis and discontinue clopidogrel 7

ARS #4 Which Patient is Best Suited for RF Ablation? 1. 80 year old with persistent atrial fibrillation 2. 68 year old symptomatic patient after 2 trials of antiarrhythmic Rx with paroxysmal atrial fibrillation 3. Obese asymptomatic patient with sleep apnea and paroxysmal atrial fibrillation 4. 64 year old with EF of 35% and LA size of 5.5 cms 5. 74 year old hypertensive with atrial fibrillation for the past 2 years and symptomatic palpitations

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NACE - Emerging Challenges in Primary Care: 2013

Atrial Fibrillation - 4

Evolving Trends in Atrial Fibrillation Management and Stroke Risk Reduction

ARS #5 Clinical Scenario: Allison M A 58 y.o. Woman with Resistant Symptomatic AF Allison has new onset AF resistant to several steps of pharmacotherapy. She has well controlled HTN and T2DM. She has a high level of awareness of her rapid heart rate, which impairs her QOL. She has heard of catheter ablation. If she undergoes successful ablation and is in sinus rhythm, what should be done about anticoagulation? 1)  Anticoagulation can be omitted once she is in sinus rhythm 2)  Anticoagulation should be used for 4-6 weeks post ablation 3)  Anticoagulation should be used indefinitely despite sinus rhythm 4)  Anticoagulation should be used for 2-3 months post 9 ablation

On a scale of 1 to 5, please rate how confident you would be in treating a patient with atrial fibrillation. 1.  2.  3.  4.  5. 

Not at all confident Slightly confident Moderately confident Pretty much confident Very confident

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NACE - Emerging Challenges in Primary Care: 2013

Atrial Fibrillation - 5

Evolving Trends in Atrial Fibrillation Management and Stroke Risk Reduction

AF: Major Teaching Points •  Stroke reduction with antithrombotic therapy (warfarin, dabigatran, rivaroxaban, apixaban) is VERY SUBSTANTIAL (±66% or more) •  ICH risk with warfarin is VERY LOW ( age 75 • Stroke rates reduced 62%

placebo warfarin

.. 8.9 3.8

2.7

AFASAK

1.4

SPAF

BAATAF

3.2

CAFA

2.5

SPINAF

EAFT

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Hart et al. Ann Intern Med. 1999;131:492-501.

Intracranial Hemorrhage During LongTerm Anticoagulation With Warfarin INR 2.0-4.5

ICH %/Year

INR 3.0-4.5 INR 2.0-4.5 INR 75)

SPAF III (AF)

INR 2.5-3.5

Turpie (PV*)

Pengo( PV*) 14

Levine MN, et al. “Hemorrhagic Complications of Anticoagulant Rx” Chest 2001;119:108S-121S

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Atrial Fibrillation - 7

Evolving Trends in Atrial Fibrillation Management and Stroke Risk Reduction

Atrial Fibrillation: Gaining Confidence in Risk Stratification

How to Use the CHADS2 Score 15

Case: Martha T, a 74 y.o. Black Female •  Brought by 46 y.o. daughter for HTN & DM re-check •  Hx: No prior arrhythmia, but reports ‘my heart seems to go a little faster sometimes in these last couple months’ •  Sister deceased due to stroke •  Meds: metformin, simvastatin, chlorthalidone, lisinopril 16

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Atrial Fibrillation - 8

Evolving Trends in Atrial Fibrillation Management and Stroke Risk Reduction

Martha T, a 74 y.o. Black Female: PE •  •  •  •  •  •  •  • 

HR 94, irregularly irregular BP 138/84 BMI: 30.4 Cardiac: No Murmur Chest: Clear Abd: WNL Neuro: WNL Extremities: no edema, pulses good 17

Martha T, a 74 y.o. Black Female: LAB •  EKG Today: Atrial Fib HR 94 •  Previous EKG (1 yr ago) ♦  NSR (72) ♦  LVH (voltage) ♦  No-ST-T wave abnormalities •  CBC, CMP WNL (3 months ago) •  A1c 7.3 (3 months prior) •  TSH = 2.1, LDL = 80 18

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Atrial Fibrillation - 9

Evolving Trends in Atrial Fibrillation Management and Stroke Risk Reduction

Martha T, a 74 y.o. Black Female with Diabetes and Hypertension •  What is Martha’s CHADS2 Score? 1)  1 2)  2 3)  4 4)  Unsure 5)  What’s a CHADS2 Score?

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CHADS2 Risk Stratification Scheme Risk Factor C Congestive heart failure

Score 1

H Hypertension

1

A Age ≥75 years

1

D Diabetes mellitus

1

S2 History of stroke or TIA

2

Rockson et al. J Am Coll Cardiol. 2004;43:929-935.

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Atrial Fibrillation - 10

Evolving Trends in Atrial Fibrillation Management and Stroke Risk Reduction

Why CHADS2 ? “The CHADS2 score is the most validated risk scheme, having been independently tested in at least 10 separate cohorts after its original derivation.” 21

You JJ, et al “Antithrombotic Therapy for Atrial Fibrillation” CHEST 2012;141(2)(Suppl):e531S-e575S

When

MIGHT THE CHA2DS2-VASc Score Help?

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Atrial Fibrillation - 11

Evolving Trends in Atrial Fibrillation Management and Stroke Risk Reduction

CHA2DS2-VASc Case Study Tina is a 72 y.o. woman with incidentally discovered atrial fibrillation when pulse irregularity was noted. She is asymptomatic, and takes no chronic medications. Her only chronic medical problem is tinnitus, for which she receives no treatment. Will this patient be better served by CHADS or CHA2DS2-VASc? 23

Tina, a 72 y.o. White Female •  What is Tina’s CHADS2 Score? 1)  0 2)  1 3)  2 4)  Unsure

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Atrial Fibrillation - 12

Evolving Trends in Atrial Fibrillation Management and Stroke Risk Reduction

CHADS2 Risk Stratification Scheme Risk Factor C Congestive heart failure

Score 1

H Hypertension

1

A Age ≥75 years

1

D Diabetes mellitus

1

S2 History of stroke or TIA

2

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Rockson et al. J Am Coll Cardiol. 2004;43:929-935.

CHADS2: Risk of Stroke National Registry of Atrial Fibrillation Participants (NRAF) # Strokes (n = 94)

NRAF Crude Stroke Rate per 100 Patient-yrs

NRAF Adjusted Stroke Rate (95% CI)†

120

2

1.2

1.9 (1.2-3.0)

463

17

2.8

2.8 (2.0-3.8)

2

523

23

3.6

4.0 (3.1-5.1)

3

337

25

6.4

5.9 (4.6-7.3)

4

220

19

8.0

8.5 (6.3-11.1)

5

65

6

7.7

12.5 (8.2-17.5)

6

5

2

44.0

18.2 (10.5-27.4)

CHADS2 Score

# Patients (n = 1733)

0 1

Scoring:

1 point: Congestive heart failure, HTN, > 75 years, and DM 2 points: History of stroke or transient ischemic attack † Expected stroke rate per 100 pt-yrs, assuming aspirin not taken Gage BF, et al. JAMA. 2001 Jun 13;285(22):2864-70.

NACE - Emerging Challenges in Primary Care: 2013

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Atrial Fibrillation - 13

Evolving Trends in Atrial Fibrillation Management and Stroke Risk Reduction

Tina, a 72 y.o. White Female •  What is Tina’s CHA2DS2-VASc Score? 1)  1 2)  2 3)  4 4)  Unsure

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CHA2DS2-VASc Risk Factor C CHF H HTN A2 Age ≥75 years D Diabetes mellitus S2 History of stroke or TIA V Vascular disease (MI, peripheral arterial disease, aortic atherosclerosis) A Age 65-74 years old Sc Sex category (female) Lip GY, et al. Am J Med. 2010;123(6):484-488. Camm AJ, et al. Eur Heart J. 2010;31(19):2369-2429.

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Score 1 1 2 1 2 1 1 1 28

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Evolving Trends in Atrial Fibrillation Management and Stroke Risk Reduction

CHA2DS2-VASc When CHADS2 Score 0 Refines stroke risk stratification in AF patients: nationwide cohort 1 Year Follow-up

12 Years Follow-up

Person Yrs

Events

Stroke rate (95%CI)

Person Yrs

Events

Stroke rate (95%CI)

CHADS2 score 0–1

40,272

1,405

3.49 (3.31–3.68)

187,200

4,599

2.46 (2.39–2.53)

CHA2DS2-VASc = 0

6,919

58

0.84 (0.65–1.08)

39,500

299

0.76 (0.68–0.85)

CHA2DS2-VASc = 1

8,880

159

1.79 (1.53–2.09)

45,926

662

1.44 (1.34–1.56)

CHA2DS2-VASc = 2

11,863

435

3.67 (3.34–4.03)

51,595

1,489

2.89 (2.74–3.04)

CHA2DS2-VASc = 3

11,473

660

5.75 (5.33–6.21)

45,799

1,933

4.22 (4.04–4.41)

CHA2DS2-VASc = 4

1,137

93

8.18 (6.68–10.02)

4,380

216

4.93 (4.32–5.64)

CHADS2 score = 0

17,327

275

1.59 (1.41–1.79)

92,531

1182

1.28 (1.21–1.35)

CHA2DS2-VASc = 0

6,919

58

0.84 (0.65–1.08)

39,500

299

0.76 (0.68–0.85)

CHA2DS2-VASc = 1

6,811

119

1.75 (1.46–2.09)

35,079

504

1.44 (1.32–1.57)

CHA2DS2-VASc = 2

3,347

90

2.69 (2.19–3.31)

16,710

353

2.11 (1.90–2.34)

CHA2DS2-VASc = 3

250

8

3.20 (1.60–6.40)

1,242

26

2.09 (1.43–3.07)

CHADS2 Score = 1

22,945

1,130

4.92 (4.65–5.22)

94,669

3417

3.61 (3.49–3.73)

CHA2DS2-VASc = 1

2,069

40

1.93 (1.42–2.64)

10,847

158

1.46 (1.25–1.70)

CHA2DS2-VASc = 2

8,516

345

4.05 (3.65–4.50)

34,885

1136

3.26 (3.07–3.45)

CHA2DS2-VASc = 3

11,223

652

5.81 (5.38–6.27)

44,557

1907

4.28 (4.09–4.48)

CHA2DS2-VASc = 4

1,137

93

8.18 (6.68–10.02)

4,380

216

4.93 (4.32–5.64)

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Olesen JB, Torp-Pedersen C, Hansen ML, Lip GY. Thromb Haemost. 2012 June;107(6):1172-9.

AF Rx as Per CHADS2 Score: AT9 (2012) CHADS2  

Rx  

0

No Rx (2B)

1

Oral Anticoagulant (1B)

>2

Oral Anticoagulant (1A)

If patient chooses treatment, ASA 81-325 mg/d (2B)

then

If patient unwilling or unsuitable, then ASA + clopidogrel (2B) If patient unwilling or unsuitable, then ASA + clopidogrel (1B)

You JJ, et al. CHEST 2012;141(2)(Suppl):e531S-e575S

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Atrial Fibrillation - 15

Evolving Trends in Atrial Fibrillation Management and Stroke Risk Reduction

FDA-Approved Antithrombotics

XII   XI   IX  

VII  

VIII  

Unfractionated Heparin

New Oral Xa

Inhibitors

Rivaroxaban Apixaban

  X Low Molecular Weight Heparin

  V

II   I  

Warfarin

New Oral IIa

(Direct Thrombin) Inhibitor

Dabigatran

Fibrin Clot

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RE-LY

Dabigatran vs Warfarin for AF •  •  •  •  •  •  • 

BASELINE CHARACTERISTICS Mean age = 71 Prior long-term warfarin: 50% Male:Female = 2:1 CHADS2 = 2.1 ASA (