ATRIAL FIBRILLATION

1. ATRIAL FIBRILLATION

2. Atrial Fibrillation Useful Resources • New draft NICE guidance www.nice.org.uk/nicemedia/live/13590/66265/66265.pdf • CHADSVASC and HASBLED - www.chadsvasc.org • AF association - http://www.atrialfibrillation.org.uk

3. Stroke • Prevalence 1.5% in people in their 60s, 10% in those over 90y. • 2 5% of all strokes in the elderly are caused by AF • 10% of the world dies from a stroke. • Risk of stroke is 4–5 x higher with AF than without. • Women who develop AF in middle age are 4x more likely than their peers to die of CVD

4. Atrial Fibrillation – the impact on the Stroke • Overall, people with atrial fibrillation are five times more likely to have a stroke than people without atrial fibrillation. • Your individual chance of having a stroke during one year ranges from from 19 in 1000 to 182 in 1,000, depending on your age and medical problems. The number of strokes that are caused by atrial fibrillation increases with age: see CHAD2VASC2 website for details of risk. • 15 in 1000 strokes in people aged 50 to 59 are caused by atrial fibrillation • 235 in 1000 strokes in people aged 80 to 89 are caused by atrial fibrillation. • Strokes caused by atrial fibrillation are more likely to be fatal than strokes caused by other things.  • About 25 in 100 people with atrial fibrillation die within 30 days of having a stroke. • About 14 in 100 people without atrial fibrillation die within 30 days of having a stroke. • People who have a stroke as a result of atrial fibrillation are more likely to have a second stroke than other people. • About 23 in 100 people with atrial fibrillation have another stroke within one year of their first stroke • About 8 in 100 people without atrial fibrillation have another stroke within one year of their first stroke. • People with atrial fibrillation are likely to be more disabled after a stroke than people with no history of atrial fibrillation.

5. Investigation of Atrial Fibrillation • How should we investigate AF? • Review in the BMJ suggests U&Es, LFTs, FBC and TSH • NICE draft 2014 suggests ECHO if: • baseline needed for long term management • In whom there is a high risk of a suspicion of underlying structural / functional heart disease (such as heart failure or heart murmur) • In whom refinement of clinical risk stratification for antithrombotic therapy is needed • Arrange an exercise test if ischaemia is suspected.

6. Atrial Fibrillation Draft NICE guidance January 2014 • Use CHA2DS2-VASc stroke risk score in the following patient groups • Symptomatic or asymptomatic paroxysmal, persistant or permanent AF • Atrial Flutter • A continuing risk of arrythmiarecurrance after cardioverson back to sinus rhythm • Offer anticoagulation to those patients in whom the CHA2DS2-VASc score is >=2 taking into account the bleeding risk. • Consider anticoagulation in men whose CAD2DS2-VASc score is 1 or greater • CHADS2-VASc score 2 = 2.2% vCHADs score of 2 = 4% risk per year. This is reduced to 1.4% if taking anticoagulation

7. Atrial Fibrillation Draft NICE guidance January 2014 • Use the HasBled score to highlight / correct and modify the following modifiable risk factors • Uncontrolled hypertension • Labile INRs • Concurrent medication e.g aspirin / NSAID • Harmful alcohol intake • A HAS-BLED score of ≥ 3 suggests the patient is at high risk and additional caution should be used, whether the patient is on aspirin or warfarin. • Do not withhold anticoagulation solely due to the fact that patients may be at risk of a fall • For most patients benefits of anticoagulation outweighs the risk

8. NOACs – Novel Anticoagulants • AF MUST BE NON - VALVULAR • APIXABAN – RIVAROXABAN : can be offered to patients with 1 or more of: • Age >= 75 • Prior stoke or TIA • Hypertension • Diabetes • Symptomatic Heart Failure • DABIGATRAN EXILATE can be offered to 1 or more of: • Age >=75 or AGE >=65 with diabetes, coronary heart disease or hypertension • Previous stroke / TIA OR systemic embolism • Symptomatic Heart Failure NY grade 2 or above • Left Ejection Fraction <40% • This guidance applies to those already diagnosed with AF as well as those newly diagnosed with it. • those currently on warfarin should be reviewed to assess the risks and benefits of continuing warfarin or swapping to one of the newer alternatives. • We must bear in mind that these are new drugs – we have limited data on long-term safety and there is no agent for rapid reversal in the event of a catastrophic bleed (SIGN 2012, 129). • There have been no good head-to-head trials and no one NOAC has shown clear superiority over another. • They do offer some benefits over warfarin in terms of stroke prevention, but the benefits are not huge. • Dabigatran (150 milligrams dose) may be more effective than warfarin at reducing the chance of having an ischaemic stroke. In one group of people, 17 in 1000 people taking warfarinf had a stroke or blood clot in the course of a year compared with 11 in 1,000 people taking dabigatan (150 milligrams) • One of the advantages of the NOACs in poor adherence is that (unlike warfarin), both Rivaroxaban and Apixiban can be put in dosette boxes (but not dabigatran). Interestingly AGH, BTHT and Leeds have all gone with Rivaroxaban as 1st choice NOAC in AF

9. Warfarin • Taking anticoagulants can affect what you can do. • There are some foods, drinks, and medicines that can interfere with anticoagulants, particularly warfarin. Some people find this affects what they can do. • Foods that contain vitamin K interfere with warfarin (broccoli, brussels sprouts, chard, kale, spinach, etc.) as does grapefruit. Alcohol can also affect how warfarin works. Medicines including non-steroidal anti-inflammatory drugs (such as ibuprofen) and antibiotics, and herbal medicines, can interfere with warfarin. • Wafarin prescribing should be re-considered if: • 2 INRs >5 or 1 INR > 8 in last 6 months • 2 INRS <1.5 in last 6 months • Time in Treatment Range over 6 months <65%

10. Aspirin in AF • NICE – do not offer asprinmonotherapysoley for stroke prevention in patient’s with AF • NICE – only consider aspirin and clopidogrel if CHA2DS2-VASc score of 2 or more and if anticoagulations if contraindicated or not tolerated • Aspirin is still overprescribed for stroke prevention in atrial fibrillation (AF) despite the potential for dangerous side effects, according to research published today. • Professor Gregory Y.H. Lip, lead author of the European Society of Cardiology (ESC) study, said: "The perception that aspirin is a safe and effective drug for preventing strokes in AF needs to be dispelled. If anything, you could say that giving aspirin to patients with AF is harmful because it is minimally or not effective at stroke prevention, yet the risk of major haemorrhage or intracranial haemorrhage is not significantly different to well-managed oral anticoagulation.” • He added: "All the contemporary guidelines1 say that aspirin should not be used for the prevention of stroke in patients with AF. And yet our study shows that aspirin is still overprescribed in these patients.

11. Group WorkWhich anticoagulation would you take ? • Which anticoagulation would you take ? • You are a 75yr old patient with non valvular AF and stable renal function. You are asked to consider anticoagulation – what would you choose ? • See word document + link to AF association decision aids • no AWCCCG restrictions on GP prescribing of NOACs at the moment (and no plans to change that in near future) so GPs allowed to initiate and prescribe if appropriate and licensed for the condition treating.

12. Contraindication to anticoagulation • The following contraindications now apply to all three new oral anticoagulants, for all doses and indications: • This may include:current or recent gastrointestinal ulceration • presence of malignant neoplasm at high risk of bleeding • recent brain or spinal injury • recent brain, spinal, or ophthalmic surgery • recent intracranial haemorrhage • known or suspected oesophagealvarices, arteriovenousmalformation,vascular aneurysms, or major intraspinal or intracerebral vascular abnormalities • Concomitant treatment with any other anticoagulant agent—eg, unfractionated heparin, low molecular weight heparin (such as enoxaparin or dalteparin), heparin derivatives (such as fondaparinux), or oral anticoagulants (such as warfarin). Exceptions are switching of therapy to or from the medicine, or when unfractionated heparin is given at doses necessary to maintain an open central venous or arterial catheter • Additional advice and information for healthcare professionals: • Special care should be taken when deciding to prescribe these anticoagulant medicines to patients with other conditions, procedures, and concomitant treatments (eg, non-steroidal anti-inflammatory drugs, antiplatelets), which may increase the risk of major bleeding  • Attention should be paid to renal function. • Impaired renal function may constitute a contraindication or recommendation not to use the anticoagulant medicine, or may require a dose reduction; recommendations differ for the three medicines

13. Rate Control • Beta blocker or rate limiting calcium channel blocker • Consider digoxin for non paroxsymal AF only if the patient is sedantary • If monotherapy not sufficient with monotherapy consider 2 of the following • Beta blocker • Diltiazem • Digoxin • Do not offer amiodarone for long term rate control

14. Rhythm Control • Consider if: • AF with a reversible cause • New onset AF – consider for new onset AF which has persisted for >48hrs • Heart Failure primarily caused by AF • Consider Amiodarone for 4 weeks before and 12 weeks after cardioversion