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Description : Check out this medical presentation on Arrhythmia, which is titled "Atrial Fibrillation and Cryptogenic Stroke: Is There a Link?", to know about atrial fibrillation and stroke, management of thromboembolic risk, outpatient monitoring considerations, and stroke risk based on atrial fibrillation burden.

Tags : Arrhythmia, Atrial Fibrillation, Cryptogenic Stroke, thromboembolic risk

Published on : Jun 02, 2021 | Views : 2218 | Downloads : 15

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Atrial Fibrillation and Cryptogenic Stroke: Is There a Link? Rhea C. Pimentel, MD Associate Professor of Medicine Fellowship Program Director, Clinical Cardiac Electrophysiology Program
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Disclosures Speakers Bureau: Medtronic Speakers Bureau: St. Jude Medical Speakers Bureau: Janssen Pharmaceuticals Speakers Bureau: Boston Scientific
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Talk Outline Epidemiology of atrial fibrillation and stroke Management of thromboembolic risk Outpatient monitoring considerations Stroke risk based on atrial fibrillation burden
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Epidemiology of Atrial Fibrillation and Stroke
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Epidemiology of Atrial Fibrillation in the US: Rising Prevalence of the Disease As of 2010, 2.66 million Americans are estimated to have AF1 Lifetime risk for developing AF is high2 1 in 4 for men and women aged 40 years Prevalence increases rapidly with age3 3.8% for persons 60 years old 9% for persons 80 years old AF prevalence is predicted to increase by 2.5 fold by 2050 AF affects 1 in 25 adults aged >60 years and 1 in 10 adults >80 years3 Predicted Prevalence of AF1 2000 Year 16 14 0 5.1 5.6 6.1 6.8 7.5 8.4 9.4 10.3 11.1 11.7 12.1 5.1 5.9 6.7 7.7 8.9 10.2 11.7 13.1 14.3 15.2 15.9 Lloyd-Jones DM et al. Circulation. 2010;121:e1-e170. 2. Lloyd-Jones DM et al. Circulation. 2004;110:1042-1046. 3. Go AS et al. JAMA. 2001;285:2370-2375. Go AS. et al. JAMA 2001;285:2370-2375.
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Independent Risk Factors for Atrial Fibrillation* Framingham Heart Study *2-Year pooled logistic regression; †AF was diagnosed in 226 men in 16,529 follow-up person-examinations; ‡AF was diagnosed in 244 women in 23,763 follow-up person-examinations; §Valvular heart disease was a significantly more potent risk factor for the development of atrial fibrillation in women than in men. DM = diabetes mellitus; HTN = hypertension; MI = myocardial infarction; CHF = congestive heart failure. Benjamin EJ et al. JAMA. 1994;271:840-844.
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Economic Impact and Public Health Burden of Hospitalizations in Those With Atrial Fibrillation Significant public health burden; total AF-attributable costs estimated at 6.65 billion1-5 Annual cost per patient ~$47005 Associated with more hospitalizations than any other arrhythmia6 Approximately one third for cardiac rhythm disturbances1 Increased hospitalizations impact quality of life and health care costs2,7 1. Fuster V et al. Circulation. 2006;114:e257-e354. 2. Le Heuzey J-Y et al. Am Heart J. 2004;147:121-126. 3. Coyne KS et al. Value Health. 2006;9:348-356. 4. Kim MH et al. Adv Ther. 2009;26:847-857. 5. Reynolds MR et al. J Cardiovasc Electrophysiol. 2007;18:628-633. 6. Singh SN et al. J Am Coll Cardiol. 2006;48:721-730. 7. Wattigney WA et al. Circulation. 2003;108:711-716.
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Distribution of $6.65 Billion (US) in Annual Atrial Fibrillation Treatment Costs for 2005 Adapted from Coyne KS et al. Value Health. 2006;9:348-356. $1.95 billion (29%) $1.53 billion (23%) $2.93 billion (44%) $235 million (4%) Outpatient Drugs Indirect inpatient Direct Inpatient
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Atrial Fibrillation Adversely Affects Quality of Life* SF-36 = 36-question Short-Form health survey. *Across all scales, both the disease specific and generic QoL was significantly worse in the AF patients compared with the controls (P<0.05 compared with AF patients); †Values represent raw mean scores ± SD; ‡P<0.001 compared with AF patients. Dorian P et al. J Am Coll Cardiol. 2000;36:1303-1309.
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*P<0.05. Atrial Fibrillation Is Associated With Increased Mortality Wolf PA et al. Arch Intern Med. 1998;158:229-234. Cumulative Mortality by Age and Sex 65-74 75-84 85-89 * * * * * * Age, y
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795,000 strokes occur annually in the US (from all causes)1 ~185,000 strokes occur in people who have already had a previous stroke1 Patients with AF have a 5-fold higher risk of stroke Over 87% of strokes are thromboembolic Strokes in Atrial Fibrillation (AF) Lloyd-Jones D et al. Circulation. 2010;121:e46-e215.
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Strokes in Atrial Fibrillation (AF) Stroke is the number one cause of long-term disability and the third leading cause of death in patients with AF Annual stroke risk is equal for paroxysmal and permanent AF Greater than 90% of thrombus accumulation originates in the Left Atrial Appendage (LAA)
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Atrial Fibrillation and Cryptogenic Stroke Why AF Matters After standard neurologic evaluation, 36% of stroke survivors are classified as cryptogenic AF and Atrial Flutter (AFL) are intermittent in 30% of stroke patients2 AF detection in cryptogenic stroke changes patient treatment Only indication for stroke patients to receive anticoagulation Prevent future strokes by treatment of underlying cause Interrupt natural history progression of atrial fibrillation 2Jabaudon D et al. Stroke. 2004;35:1647-51. 3Tayal AH et al. Neurology. 2008;71:1696-701
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Clinical Presentation of Atrial Fibrillation AF presents with a wide range of symptoms1 May also be asymptomatic Impact of asymptomatic AF2 Potential for underlying electrical and structural damage to atrial myocardium While AF symptoms alone may not always be severe, untreated disease can result in significant morbidity and mortality3 PALPITATIONS LIGHT- HEADEDNESS FATIGUE DYSPNEA SYNCOPE CHEST PAIN THROMBO- EMBOLISM DEATH 1. Fuster V et al. Circulation. 2006;114:e257-e354. 2. Page RL et al. Circulation. 2003;107:1141-1145. 3. Stewart S et al. Am J Med. 2002;113:359-364.
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Occurrence of Asymptomatic AF and Reliability of Symptoms 1 Strickberger SA, et al. Heart Rhythm. 2005;2:125-131. Methods: “Almost 95% of documented AT episodes were asymptomatic, and symptoms attributed to atrial fibrillation were associated with AT only approximately 15% of the time.” “No significant differences in the specific symptoms that correlated with or without a documented atrial tachyarrhythmia were observed.” Multicenter trial following 48 patients for 12 months to correlate pacemaker-detected atrial tachyarrhythmia (AT) events with symptoms Results/Conclusions: Strickberger1
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Management of Thromboembolic Risk
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Copyright © The American College of Cardiology. All rights reserved. From: 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society J Am Coll Cardiol. 2014;64(21):e1-e76. doi:10.1016/j.jacc.2014.03.022 Summary of Recommendations for Risk-Based Antithrombotic Therapy
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The CHADS2 Scoring System A points based system for predicting risk of stroke in AF, based on key risk factors1,2 Prior stroke or TIA 2 points Age >75y 1 point Hypertension 1 point Diabetes mellitus 1 point Heart failure 1 point TIA = transient ischemic attack 1. ACC/AHA/ESC 2006 guidelines J Am Coll Cardiol 2006;48:854-906 2. Gage BF et al. JAMA 2001;285:2864–70.
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CHA2DS2-VASc Lip GY, et al., Chest 137, 263-272, 2010 maximum score is 9 since age may contrubute 0, 1, or 2 points
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Comparison of Stroke Risk Friberg L: Eur Heart J 2012;33:1500-1510.
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HAS-BLED score Hypertension, Abnormal Liver or Renal Fxn, Stroke, Bleeding, Labile INR, Elderly, Drugs or Alcohol Chest. 2010 Nov;138(5):1093-100
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ACTIVE-W study Patients with atrial fibrillation were randomized to standard therapy with oral anticoagulation (warfarin) or clopidogrel plus aspirin and followed for approximately two years When halted in September 2005, ACTIVE-W had enrolled its target of 6600 patients. Data safety and monitoring board stopped the trial after a clear increase in efficacy was seen in the warfarin arm of the trial. Connolly S. American Heart Association Scientific Sessions 2005; Nov 13-16, 2005; Dallas, TX.
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Connolly S. American Heart Association Scientific Sessions 2005; Nov 13-16, 2005; Dallas, TX. Vascular Events and Major Bleeding: ACTIVE-W
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Outpatient Monitoring Considerations
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Recognition of AF may be difficult due to its often ‘silent’ nature -- 1/3 of patients not aware of so-called ‘asymptomatic AF Much earlier detection of the arrhythmia might allow Timely introduction of therapies to treat AF (rate/rhythm control) Interruption of the natural progression of AF -- Assists in the decision to initiate or discontinue anticoagulation therapy Ability to document onset mechanism of AF to aide in treatment Cardiac Monitoring for Diagnosing AF Camm AJ et al. Eur Heart J. 2010;31:2369-429. Jabaudon D et al. Stroke. 2004;35:1647-51.
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Cardiac Diagnostics Landscape 24-Hour Holter Event Recorder 14-30 Day Mobile Cardiac Telemetry Monitor Insertable Cardiac Monitor Source: Frost & Sullivan report: North American Cardiac Monitoring and Diagnostic Services Markets
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Long term monitor Up to 14 days of monitoring Way for patient to report symptoms during this time No access to EKG’s during the monitoring period Z100A4770.01 | Feb. 2013 -FDA approved for up to 14 days of continuous monitoring -Patients may “mark” symptoms during this time -No access to rhythm strips during monitoring period
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AliveCor Fully secure, HIPAA-compliant online access FDA approved December 2012 Sold to US licensed medical providers as a prescription to record, transmit and store single channel EKG Not covered by insurance Currently only works with iPhones
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As Cardiac Monitoring Evolves, Diagnostic Yield Improves Event Monitor: Non-looping CardioNet MCOT (Mobile Cardiac Outpatient Telemetry) Holter Monitor AF Auto-trigger Monitor Invasive Implantable Loop Recorder 5% – 13% 15% Event Monitor: Looping Memory Syncope 6% – 25% Palpitations 39% – 68% 36% ECG symptom correlation 45% – 88% 88% Assar MD et al. Am J Cardiol. 2003; Fechter P. Schweiz Med Wochenschr. 1991; Fogel RI et al. Am J Cardiol. 1997; Gibson TC et al. Am J Cardiol. 1984; Kinlay S et al. Ann Intern Med. 1996; Krahn AD et al. Circulation. 2001; Krahn AD et al. PACE. 2004; Linzer M et al. Am J Cardiol. 1990; Reiffel JA et al. Am J Cardiol. 2005; Rothman SA et al. J Cardiovasc Electrophysiol. 2007; Zeldis SM et al. Chest. 1980; Zimetbaum P et al. Am J Cardiol. 1997. Relative diagnostic yield
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Stroke Risk Based on Atrial Fibrillation Burden
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From: 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society J Am Coll Cardiol. 2014;64(21):e1-e76. doi:10.1016/j.jacc.2014.03.022 Summary of Recommendations for Electrical and Pharmacological Cardioversion of AF and Atrial Flutter
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Relationship Between Atrial Arrhythmia Burden and Stroke Risk (TRENDS Study) 4 Glotzer T, et al. Circ Arrhythm Electrophysiol. 2009;2:474-480. Methods: /AF burden ≥ 5.5 hours on any of 30 prior days appeared to double TE risk Prospective, observational study analyzing 2,486 patients with ≥ 1 stroke risk receiving pacemakers or defibrillators that monitor atrial tachycardia (AT)/AF burden Annualized TE rates were determined according to AT/AF burden subsets: zero, low (< 5.5 hours [median duration of subsets with nonzero burden]), and high (≥ 5.5 hours) Results/Conclusions: How Much AF For a Stroke: 5.5 Hrs?
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TRENDS Study Subgroup Analysis Newly Detected AF (“NDAF”) in Patients with Thromboembolic Events Ziegler P. et al. Stroke. 2010;41 163 patients with previous ischemic stroke/TIA, no known AF, were continuous monitored via pacemaker or ICD NDAF > 5 minute duration were found in 28% patients. 73% of patients had newly detected AT/AF on <10% of follow-up days
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How Much AF for a Stroke: 6 min? Assert Study Results: 2580 pts with mean CHADS2 score of 2.29 followed prospectively for 2.5 yrs 10.1% pts with >1 Subclinical AF episode (>190 bpm for >6 min) within first 3 months Associated with increased risk of Clinical AF (HR 5.56 [3.78-8.17]; p<0.001) Associated with increased risk of Ischemic Stroke or Systemic Embolism (HR 2.49 [1.28-4.85]; p=0.007) Cumulative Hazard Healey, JS et al. Subclinical Atrial Fibrillation and the Risk of Stroke. N Engl J Med 2012;366:120-129.
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Among patients with AT/AF episodes >17.72 hours, annual rate of stroke or systemic embolism was 4.89 (95% CI, 1.96 to 10.07)
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Conclusions Atrial fibrillation (AF) is a common disorder with significant morbidity, mortality, economic and social considerations Appropriate therapy for AF is dependent on a patient’s risk factors for thromboembolism Long term cardiac monitoring can help diagnose AF and guide appropriate treatment Prior observational studies have demonstrated a link between AF burden and stroke risk
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Thank You
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