Why is Atrial Fibrillation Undertreated in Women Compared to Men?

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1 Why is Atrial Fibrillation Undertreated in Women Compared to Men? Professor Andrew Sindone Concord and Ryde Hospitals Disclosure Professor Sindone has indicated that he has a relationship which in the context of this presentation, could be perceived as a real or apparent conflict of interest but does not consider that it will influence his presentation. Professor Sindone has received honoraria, speaker fees, consultancy fees, is a member of advisory boards or has appeared on expert panels for: Abbott, Alphapharm, Aspen, Astra Zeneca, Bayer, Biotronik, Boehringer Ingleheim, Bristol Myer Squibb, Cube, CSL, Elixir, General Electric, Glaxo Smith Kline, Guidant, HealthEd, Heart Foundation of Australia, Jansen Cilag, Johnson and Johnson, Medtronic, Menarini, Merck Sharp and Dohm, Novartis, NSW Department of Health, Ogilivy, Pfizer, Phillips, Roche, Sanofi Aventis, Schering Plough, Servier, Solvay, St Jude, Sunshine Heart, Ventracor, Vifor (Sorry if I forgot anyone) AF is a silent and under-diagnosed condition Atrial fibrillation (AF) is common with potentially debilitating / life-threatening consequences 1,2 Estimated total prevalence of non-valvular atrial fibrillation (NVAF) in Australians aged 50 years in ,511 people Undiagnosed 91,302 people Diagnosed 365,209 people Deloitte Access Economics. Off beat: Atrial fibrillation and the cost of preventable stroke Camm AJ et al. Eur Heart J 2010; 31: Deloitte Access Economics. Off beat: Atrial fibrillation and the cost of preventable stroke AF is common among older patients Many Australians with NVAF are inadequately anticoagulated 1 Adelaide stroke incidence study: 92 of the 109 cardioembolic strokes were attributable to AF 57 of these patients had a prior diagnosis of AF 1 of patients with AF (diagnosed/undiagnosed) 85% were inadequately anticoagulated Ball J et al. MJA doi: /mja Leyden JM et al. Stroke 2013; 44:

2 Potential consequences of AF Introducing Jill 1. Camm AJ et al. Eur Heart J 2010; 31: Gladstone DJ et al. Stroke 2009; 40: years old Married with 3 children and 5 grandchildren BMI 21.0 (weight 58 kg, height 1.66 m) Hypertension diagnosed 4 years ago (currently taking telmisartan 40 mg) BP 142/92 mmhg Serum creatinine 79 µmol/l Suspected atrial fibrillation (AF) Not an actual patient Who Should Be Referred to a Cardiologist? Most patients with non-valvular AF can be initiated on a NOAC by their GP. Caution should be exercised in patients who have: Renal impairment (calculate creatinine clearance) Valvular heart disease Gastrointestinal or intracranial bleeding in the last one to two years Frail & / or elderly When in doubt, a simple phone call can make things easier Jill s GP refers her to a cardiologist During her recent consultation her pulse was noted to be 163 bpm and irregular. She also reports occasional palpitations with fatigue. ECG at the time of her consultation suggests AF. I have initiated atenolol 50 mg for rate control. She was diagnosed with hypertension 4 years ago, managed with telmisartan 40 mg (current BP 142/92 mmhg), and has moderately impaired renal function (serum creatinine 79 µmol/l, egfr 61 ml/min/1.73m 2 ). She does not have diabetes and has no history of cardiovascular events. ESC Guideline recommendations: Warfarin vs NOACs ESC 2012 Guidelines: Selection of Patients for Anticoagulation 1 Non-valvular atrial fibrillation Valvular atrial fibrillation Yes < 65 years and lone AF including women NOACs are recommended as broadly preferable over vitamin K antagonists in the vast majority of patients with NVAF, when used as studied in clinical trials 1 Stroke risk assessment using CHA 2DS 2-VASc Oral anticoagulant Assess bleeding risk (HAS-BLED score); consider patient values/preferences No antithrombotic therapy Adapted from Camm, Novel oral anticoagulants: rivaroxaban, dabigatran apixaban Vitamin K antagonist Camm JA et al. Eur Heart J 2012; 33: Camm AJ et al. Eur Heart J 2012;33:

3 What is Valvular AF? Valvular Atrial Fibrillation Metallic Prosthetic Valve Replacement Haemodynamically Significant Mitral Stenosis Non-Valvular Atrial Fibrillation Everything Else NVAF is defined as atrial fibrillation without the presence of haemodynamically-relevant mitral stenosis or mechanical heart valve Antiplatelet therapy in AF has an unfavourable risk:benefit ratio Aspirin monotherapy is not recommended in AF 1 * evidence for effective stroke prevention in AF is weak a potential for harm exists (risk of major bleeding or intracranial haemorrhage similar to anticoagulant) Antiplatelet combination therapy (aspirin plus clopidogrel) is associated with greater risk of bleeding than aspirin monotherapy 1 *Aspirin use should be limited to the few patients who refuse any form of oral anticoagulant 1 Camm JA et al. Eur Heart J 2012; 33: HAS-BLED identifies potentially modifiable risk factors for bleeding ESC Guidelines for the management of atrial fibrillation: The HAS-BLED score allows clinicians to make an informed assessment of bleeding risk; however, it should not be used to exclude eligible patients from anticoagulation therapy 1 If HAS-BLED 3: Identify and correct any modifiable risk factors for bleeding Use anticoagulation with caution and regular review 1. Camm JA et al. Eur Heart J 2012; 33: Optimising International Normalised Ratio AUSTRALIA Mean time in therapeutic range (INR 2 3) 50 68% 1 The Promise of NOACs Simplified dosing regimen, no dietary restrictions, predictable anticoagulation and no need for routine coagulation monitoring. Can be given at fixed doses Less labourintensive Less impact on patient s daily life Improved compliance Reduced potential for food and drug interactions 2 80 % of strokes occur at INR < 2 Reduced administrative costs Improved QoL Improved efficacy and safety Adapted from Blann et al Australian Government Department of Health and Ageing. Review of anticoagulation therapies in atrial fibrillation. 2. Fang MC et al. Ann Intern Med 2004; 141: Blann AD et al. BMJ 2003; 326: Ansell 18J et al, 2004; 2. Mueck W et al, 2007; 3. Mueck W et al, 2008; 4. Mueck W et al, 2008; 5. Raghavan N et al, 2009; 6. Shantsila E, Lip GY

4 Continued follow-up is essential for Jill Make early follow-up appointment for Jill at the time of initial consultation: Reassess Jill s understanding of NVAF and its management Assess Adherence Co-medications Side effects, including bleeding events Provide opportunity for Jill to ask questions Check renal function at baseline then at least annually 1 Assess as required during intermittent illnesses that may affect renal function or in conditions when a decline in renal function is suspected

5 # # SEE = Systolic Embolic Event

6 The art of anticoagulation: patient-centred care Switching from warfarin to a NOAC in patients with AF Discontinue warfarin Monitor INR INR 3 Initiate rivaroxaban INR <2 Initiate dabigatran or apixaban or 72 hours NOACs, unlike warfarin, are immediate-acting drugs with C max of 2 to 3 hours Apixaban Product Information 2013; Dabigatran Product Information 2013; Rivaroxaban Product Information

7 Summary AF is the most common cardiac arrhythmia Prevalence of AF is increasing Embolization of blood clots formed in the atria of the heart leads to stroke and thromboembolic complications AF increases the risk of stroke 5-fold and is responsible for nearly one-third of all strokes Risk of stroke persists in asymptomatic or paroxysmal AF Factors increasing stroke risk include: Previous stroke or transient ischaemic disease Advancing age Chronic heart disease Rheumatic valvular disease or prosthetic valve Hypertension Diabetes mellitus Assessment of stroke risk is important to guide therapy 37 Thank You