Why is Atrial Fibrillation Undertreated in Women Compared to Men? Professor Andrew Sindone Concord and Ryde Hospital s 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 consequences 1,2 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 people Diagnosed 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 anticoagulated 1 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 AF 1 of patients with AF (diagnosed/undiagnosed) were inadequately anticoagulated 85%
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A Case Challenge - Healthed 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
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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,
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