PERFECT AF MANAGEMENT

Dr Joe Mills

Consultant Interventional Cardiologist

Cardiac Lead, North-West Coast Clinical Network

Liverpool Heart & Chest Hospital NHS FT

PREVENT,

DETECT,

PROTECT and………………

• In the absence of head-to-head trials, it is not appropriate to be

definitive on which DOAC is the best, given the heterogeneity of the

different trials.

• NICE concluded that all newer oral anticoagulants appear to have

comparable efficacy for the composite primary and bleeding outcomes.

1.

• In the absence of a specific clinical reason to select a particular DOAC

(e.g. patients with previous stroke may benefit more from dabigatran

150mg twice daily), the North West Coast Strategic Clinical Network

recommends that the DOAC with the lowest acquisition cost as the first

line DOAC for patients with AF. Currently this is edoxaban which is also

available through a rebate scheme resulting in a further significant price

reduction compared to the most expensive DOAC.

• This statement has been approved by Dr Joe Mills, the Cardiac NetworkClinical Lead and the NWSCN Cardiology and Stroke Pharmacist Forum.

CLINICAL CASE – Terry the electrician

•54 yr old, married, 3 children•Long standing hypertension•Usually well, rarely goes to GP•Flu at Xmas 2018 – unable to work•Sx improved after 2 weeks but still fatigued•Noticed palpitations and SOB•Forced to the GP by his wife (end of Jan)

CLINICAL CASES

• Last blood tests 2 years ago – no sig abnormalities

• Medication: Ramipril 5mg OD

• Pulse irreg, chest clear, BP 162/95

• ECG performed

Case 1: ecg

CLINICAL CASES

A&E:

•CXR / bloods inc Tn (!!) – all NAD•Started on Bisoprolol 2.5mg + NOAC•Echo arranged •Cardiology referral made•Discharged home

TTE

EF: 25%

Dilated LA/LV

Mild MR

Normal RH

Subsequent Management

• GP commenced MRA, Ramipril & BB increased

• S/B cardiology SpR in April

• Referral for CMR

• Remains limited by fatigue, SOB, becoming depressed

• Sporadic work

• Family / social life all suffering

THE GREAT DEBATE

AF/PAF – some important considerations:

• Independently predicts mortality (Odds Ratio 1.5 in men,1.9 women)

• AFFIRM, RACE, STAF – no difference in mortality between rate or rhythm control over 3 yr f/up (most patients had little/no symptoms)

• When studies are analysed according to ACTUAL rhythm (rather than on an “intention-to-treat” basis) – sinus rhythm appears superior

• Restoring SR has been shown to improve LVEF, reduce LA size, improve exercise capacity, improve QoL.

• Maintaining SR is challenging – achieved in 35-65% patients

AF affects quality of life

• PAF

– Symptoms during attacks

– Psychological effect of paroxysmal condition

• When will it occur, how will I feel

• Lack of control –different from arthritis/COPD

• Persistent AF

– Breathlessness, Tiredness/lethargy, Palpitations

• Fear of stroke

• Side effects of drugs

• AF affects QOL equally in spouses as well!*

*PACE 2011;34:804-9

QOL in cardiovascular conditions

DC CardioVersionAF Ablation &

Ablate and Pace Strategies

Ablate and Pace

• Involves AV node ablation and permanent pacemaker implantation

• Smooths rate control

• Appropriate for

• Patients with Poorly controlled ventricular rates

• Patients unsuitable for rhythm control

• Permanent AF

• Large LA, Structural heart disease

• Irreversible procedure: some patients do not tolerate ventricular pacing

Stroke Risk ReductionLeft Atrial Appendage Occlusion

Limitations of NOACs

N Major

Bleeding

N (%/yr)

Intracranial

bleeding

N (%/yr)

Significant GI

bleed

N (%/year)

Treatment

abandoned

by 1 year

Dabigatran

150 mg BD

6076 409 (3.4) 38 (0.32) 188 (1.6) 22%

Dabigatran

110 mg BD

6015 347 (2.9) 27 (0.23) 137 (1.2) 20%

Rivaroxaban

20 mg OD

7111 395 (3.6) 55 (0.5) 224 (3.1) 24%

Edoxaban

60 mg OD

7035 418 (2.8) 61 (0.39) 232 (1.51) ?

Apixaban

5 mg BD

9088 327 (2.1) 52 (0.33) 105 (0.8) 16%

• PROTECT-AF trial (707 patients):

• LAAO equal to Warfarin

• 5% procedural complications

• Longer term follow up (Mean 2.3 years)*

• LAAO superior to Warfarin (3% vs 4.3%)

• LAAO better QOL than Warfarin

• Procedural complication rates now 2-3%**

• Procedural stroke 0%

•Circulation 2013; 127:720-9

** Circulation 2011: 123:417-424

Percutaneous Left atrial appendage device occlusion

Commissioning through Evaluation

• NHS England for 3 procedures

• LAAO

• ASD/PFO devices

• Mitraclip

• 24 centres with expression of interest

• 10 sites selected

• 30 procedures/ year for 3 years

• Need for MDT and national audit

Service Specification DocumentPatient selection

• Patients with AF and

• a high stroke risk (CHADSVASc score of 2 or more)

• Contraindication to oral anticoagulation (previous bleed or high bleeding risk)

• Previous Stroke in spite of adequate OAC

• Referrals from secondary care to a MD Team

• Not offered as a lifestyle choice

Atrial Fibrillation Commissioning toolkit

Recommendation 1Easily accessible lifestyle support services

should be commissioned to enablepatients with AF to reduce their risk of

stroke

Conclusions

• AF/PAF adversely affect functional status, QoL, cardiac parameters and mortality

• DCCV should be considered for ALL patients with persistent AF and……symptoms or a reversible cause or recent onset

• Modern success rates for AF ablation approach 80-90%, especially in Paroxysmal AF

• Ablate and Pace are options for selected patients

• LAA occlusion for those patients who are unsuitable for OAC

• Do NOT forget – lifestyle and CVD risk factor treatment

Annual Conference

Manchester 5-7 June 2017

The BACPR Standards and Core Components for

Cardiovascular Disease

Prevention and Rehabilitation

2017 (3rd Edition)

http://www.bacpr.com/pages/page_box_contents.asp?PageID=791

Annual Conference

Manchester 5-7 June 2017

• Patient-centred

• Bio-psycho-social

• HBCE is the core element

• Requires MDT to deliver

• Emphasis on;

• Audit

• Evaluation

• Long-term

outcomes

Reported attendance at CPRPs 2007-2018

*Commencement of new coding system employed

Percentages of patients who had an MI, a PCI, or a CABG taking part in CR in England, Northern Ireland and Wales

2007/8 2008/9 2009/10 2010/11 NACR 2013 Report

2011/12

NACR 2014 Report

2012/13

NACR 2015 Report

2013/14

LATEST REPORT

MI 34% 39% 41% 44% 46% 33% 38% 35%

MI + PCI 53% 54% 54%

PCI 30% 28% 31% 31% 28% 40% 40% 45%

CABG 68% 76% 71% 74% 70% 80% 59%* 70%

TOTAL 38% 41% 42% 44% 43% 45% 47% 50%

Psychological wellbeing

Physical wellbeing

Exercise Capacity

www.croi.ie

Questions??

Information available from

Joseph.mills@lhch.nhs.uk

www.bacpr.com

bacpr@bcs.com

@bacpr

mailto:bacpr@bacpr.com