Stroke Prevention in Atrial Fibrillation

How can the Pharmacy Technician help?

Jill Walton-NevinsCardiovascular AdviserBoehringer Ingelheim

AF is the most common heart rhythm disturbance4

It is estimated 1 in 4 individuals aged 40 years will develop AF4

In 2007, 6.3 million people in the US, Japan, Germany, Italy, Spain, France and UK were living with diagnosed AF5

Due to the aging population, this number is expected to double within 30 years6

Incidence and prevalence…

4. Lloyd-Jones DM, et al. Circulation 2004;110:1042-1046. 5. Decision Resources. Atrial Fibrillation Report. Dec 2008. 6. Go AS, et al. JAMA 2001;285:2370-2375.

4.56

12.93

0.64

40.06

26.31

0.21

7.28

2.37

17.69

28.67

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<55 55-64 65-74 75-84 ≥85Age Group (years)

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Age- and Sex-Adjusted Incidence of AF in 1995-2000

Projected Number of Persons With AF in the United States

Between 2000 and 2050

5.1

14.3

11.7

8.96.7

15.9

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Relationship to age…

1. Miyasaka Y et al. Circulation. 2006;114:119-125.

Risk Factors…

Cardiac Cardiac Atrial hypertrophy Ischaemic heart disease Rheumatic heart disease Hypertension Sick sinus syndrome Wolf-parkinson-white

Non-CardiacNon-Cardiac Acute infections (pneumonia) Electrolyte imbalances Lung cancer Pulmonary embolism Thyrotoxicosis

7.Maurits A et al. Pathophysiologyand prevention of atrial fibrillation. Circulation 2001;103:769-777

Classification of AF subtypesTypes of atrial fibrillation…

First diagnosed episode of atrial fibrillation

Paroxysmal(usually ≤48 Hrs)

Persistent(requires CV)

Long Standing(persistent > 1year)

Permanent(accepted)

11.www.escardio.org/guidlines. European Heart Journal (2010) 31, 2369-2429.

If sustained AF: Palpitations +/- Chest pain Dyspnoea +/- Dizziness Reduced exercise tolerance (often significant) Panic attacks/Agoraphobia/depression

If Paroxysmal: As above, but may be more severe (less well

tolerated) Often preceded by exertion, ‘thump’ in the chest,

fatigue, alcohol, coffee and other stimulants

Symptoms…

12.Weert, H. Diagnosing atrial fibrillation in general practice. BMJ. 2007. 335:355-356.

Perform opportunistic pulse check in those >65 particularly those patients presenting with:

Breathlessness or dyspnoea Palpitations Syncope or dizziness Chest discomfort Stroke/TIA

Also perform routinely when monitoring patients with:

Hypertension Diabetes Existing cardiovascular disease

Primary care…

MANUAL pulse checking will give a strong clue

‘Irregular irregularity’ – any rate

Variable strength of individual pulses

Often omitted since introduction of automated BP machines, etc.

12 Lead ECG NICE – an ECG should be

performed in all patients, whether symptomatic or not, in whom AF is suspected because an irregular pulse has been detected

Diagnosis…

Taking the pulse...

The radial pulse…

Very easy to do with practice 2 or 3 fingers (not thumb) Along radius (in line with the

patient’s thumb) 30 secs usually sufficient

Give it a go!

Stroke risk assessment with CHADS2

CHADS2 criteria ScoreCongestive heart failure 1Hypertension 1Age ≥75 yrs 1Diabetes mellitus 1Stroke/transient ischaemic attack

2

CHADS2total score

Risk of stroke (%/year) (95% CI)*

0 1.9 (1.2–3.0)1 2.8 (2.0–3.8)2 4.0 (3.1–5.1)3 5.9 (4.6–7.3)4 8.5 (6.3–11.1)5 12.5 (8.2–17.5)6 18.2 (10.5–27.4)

Gage BF et al. JAMA 2001;285:2864–70

*Adjusted stroke rate = expected stroke rate per 100 patient-years based on exponential survival model, assuming aspirin not taken

Stroke risk assessment with CHA2DS2-VASc

CHA2DS2-VASc criteria ScoreCongestive heart failure/left ventricular dysfunction

1

Hypertension 1Age 75 yrs 2Diabetes mellitus 1Stroke/transient ischaemic attack/TE

2

Vascular disease(prior myocardial infarction, peripheral artery disease or aortic plaque)

1

Age 65–74 yrs 1Sex category (i.e. female gender)

1

CHA2DS2-VASc total score

Rate of stroke/other TE (%/year) (95% CI)*

0 0 (0–0)1 0.6 (0.0–3.4)2 1.6 (0.3–4.7)3 3.9 (1.7–7.6)4 1.9 (0.5–4.9)5 3.2 (0.7–9.0)6 3.6 (0.4–12.3)7 8.0 (1.0–26.0)8 11.1 (0.3–48.3)9 100 (2.5–100)

*Theoretical rates without therapy corrected for the % of patients receiving aspirin within each group, assuming 22% reduction in risk with aspirin

Lip GYH et al. Chest 2010; 137;263-272. TE = thromboembolism

AF is a major independent risk factor of stroke with the risk increasing with age 14

Stroke is the third most common cause of death in the UK 15

AF – The real cost…

14. NICE AF June 2006. 15. National stroke strategy, Dec 2007.

Any Questions?

Stroke…

‘A clinical syndrome characterised by rapidly developing clinical symptoms and/or signs of focal and at times global loss of

cerebral function, with symptoms lasting more than 24 hours or leading to death, with no apparent cause other than that of

vascular origin’. (Hatano 1976)

Warlow C et al. (2008). Stroke Practical Management: 39–40

Defining the difference…

Transient ischaemic attack - TIA

Stroke like symptoms but lasting less than 24 hours.1

Most last for 15-30 minutes.1

Symptoms completely resolved once flow returns.1

Brain is temporarily deprived of blood by tiny emboli which break up very quickly. “angina of the brain”. 1

TIA’s do not result in permanent damage but are a warning sign of further events.1

1. Stroke Association 2010; 2. Choi J Y; 2003

TIA’s are a warning of a stroke

Following a TIA:

8-12% another TIA or stroke in 1st week15% by one month30% in 5 yearsNeed for investigation and secondary prevention

BMJ 2004; 328:326-8

Transient Ischaemic Attack - TIA

Health Leader 2003; University of Texas Health Science Centre at Houston

Each year in the UK an estimated 150,000 people have a stroke and over 67,000 of these will die as a result. This equates to one person every 5 mins.

Stroke accounts for 9% of all deaths in men and 12% of deaths in women in the UK and is the leading cause of long term disability.

Stroke Epidemiology…

‘What is a stroke?’ 2010 Stroke Association.

People of African or Caribbean origin and men of south Asian origin are more likely to have a stroke than people from other ethnic groups.2

A quarter of stroke occur in people under the age of 65.2

Strokes are the third most common cause of death in the UK1

‘What is a stroke?’ 2010 Stroke Association. 1 National Audit Office. Progress in improving stroke care. 2010 2

It was estimated that in 2008-09 the direct care cost of stroke was at least £3 billion annually, within a wider economic cost of about £8 billion.

Around 300,000 people are living with moderate to severe disabilities as a result of stroke.

Without preventative action, there is likely to be an increase in strokes as the population ages

National Audit Office. Progress in improving stroke care. 2010

Risk Factors…

Stroke, like heart attack, is a vascular disease risk factors Stroke, like heart attack, is a vascular disease risk factors include:include:

Hypertension DyslipoproteinaemiaAtrial FibrillationDiabetesSmokingUnhealthy diet or high alcohol intakePrevious stroke or TIAFamily history

National Audit Office. Progress in improving stroke care. 2010

AF & Stroke Burden

12,500 strokes annually in England in patients with AF 1

The cost per stroke due to AF is estimated to be £11,900 in the first year after stroke occurrence 1

AF-related stroke has a 30-day mortality of around 25% 2

AF-related stroke has a 1-year mortality of around 50% 2

Ref 1: Commissioning for Stroke Prevention in Primary Care - The Role of Atrial Fibrillation. 2009. www.improvement.nhs.ukRef 2: Marini C, et al. Stroke 2005;36:1115-1119.