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)…

Atrial fibrillation (AF) is

common

with potentially

debilitating / life-threatening

consequences1,2

Deloitte Access Economics. Off beat: Atrial fibrillation and the cost of preventable stroke. 2011. 2. Camm AJ et al. Eur Heart J 2010; 31: 2369–429

AF is a silent and under-diagnosed condition

Undiagnosed

91,302 peopleDiagnosed

365,209 people

Estimated total prevalence of non-valvular atrial fibrillation (NVAF)

in Australians aged ≥50 years in 2011

Deloitte Access Economics. Off beat: Atrial fibrillation and the cost of preventable stroke. 2011

456,511 people

AF is common among older patients

Ball J et al. MJA 2015. doi: 10.5694/mja14.00238.

Many Australians with NVAF are

inadequately anticoagulated1

1. Leyden JM et al. Stroke 2013; 44: 1226-31.

Adelaide stroke incidence study:

92 of the 109 cardioembolic strokes were attributable to AF

57 of these patients had a prior diagnosis of AF1

of patients with AF (diagnosed/undiagnosed)

were inadequately anticoagulated 85%

Potential consequences of AF

1. Camm AJ et al. Eur Heart J 2010; 31: 2369–429. 2. Gladstone DJ et al. Stroke 2009; 40: 235–40.

Introducing Jill

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)

80 years old

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/1.73m2).

She does not have diabetes and has no history of cardiovascular events.

ESC Guideline recommendations:

Warfarin vs NOACs

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

Camm JA et al. Eur Heart J 2012; 33: 2719–47

ESC 2012 Guidelines: Selection of Patients

for Anticoagulation1

Non-valvular atrial fibrillation Valvular atrial fibrillation

< 65 years and lone AF including women

Stroke risk assessment using CHA2DS2-VASc

0 1 ≥2

Assess bleeding risk (HAS-BLED score);

consider patient values/preferences

Novel oral anticoagulants:

rivaroxaban, dabigatran

apixaban

Vitamin K antagonistNo antithrombotic therapy

Oral anticoagulant

Yes

1. Camm AJ et al. Eur Heart J 2012;33:2719–47.

Adapted from Camm, 20121

What is “Valvular” AF?

Valvular

Atrial Fibrillation

Non-Valvular Atrial

Fibrillation

Metallic Prosthetic Valve

Replacement Everything Else

Haemodynamically

Significant

Mitral Stenosis

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 AF1*

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 monotherapy1

Camm JA et al. Eur Heart J 2012; 33: 2719–47

*Aspirin use should be limited to the few patients who refuse

any form of oral anticoagulant1

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 therapy1

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: 2719–47

Optimising

International Normalised Ratio

Adapted from Blann et al. 20033

2

1. Australian Government Department of Health and Ageing. Review of anticoagulation therapies in atrial fibrillation. 2. Fang MC et al. Ann Intern Med 2004; 141: 745–52.

3. Blann AD et al. BMJ 2003; 326: 153–6.

AUSTRALIA

Mean time in

therapeutic

range

(INR 2–3)

50–68%1

80 % of strokes occur at INR < 2

The Promise of NOACs

18

Improved

compliance

Improved

efficacy

and safety

Less impact on

patient’s daily

life

Improved

QoL

Less labour-

intensive

Reduced

administrative

costs

Reduced potential

for food and drug

interactions

1. Ansell J 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. 2008.

Simplified dosing regimen, no dietary

restrictions, predictable

anticoagulation and no need for

routine coagulation monitoring.

Can be given at fixed doses

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 annually1

Assess as required during intermittent illnesses that may affect

renal function or in conditions when a decline in renal function is

suspected

≠

≠

# SEE = Systolic Embolic Event

#

The art of

anticoagulation: patient-centred care

Switching from warfarin to a NOAC in patients

with AF

Discontinue warfarin

Monitor INR

INR ≤3

INR <2

Initiate rivaroxaban

Initiate dabigatran

or apixaban

• NOACs, unlike warfarin, are immediate-acting drugs

with Cmax of 2 to 3 hours

Apixaban Product Information 2013; Dabigatran Product Information 2013; Rivaroxaban Product Information 2013. 35

or 72 hours

37

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

Thank You