Atrial Fibrillation (AF) & the Prevention of Stroke:

A Patient-Centered Approach

This Non-CME educational program is sponsored in part by Boehringer Ingelheim Pharmaceuticals, Inc.
*Please note: Brochure content is provided by pmiCME and American College of Physicians (ACP)

Printed December 2011

AF: Treatment Options

Rate Control Maintenance of SR Stroke Prevention

Pharmacologic
Ca blockers
2+

Pharmacologic
Prevent Remodeling CCB ACE-I, ARB Statins Fish oil

Nonpharmacologic

Pharmacologic
Warfarin Aspirin

b-blockers Digitalis Amiodarone

Class IA Class IC Class III b-blocker

Catheter ablation Pacing Surgery Implantable devices

Thrombin Inhibitor

Nonpharmacologic
Ablate and pace

Nonpharmacologic
Removal/isolation LA appendage

Notes: There are 3 priorities for the management of patients with

AF: rate control, maintenance of sinus rhythm (SR), and stroke prevention. A combination of strategies may be appropriate in some patients. Nonpharmacologic approaches to maintaining sinus rhythm (MAZE procedure, pulmonary vein isolation) are important adjunctive therapies to consider for patients who are already undergoing cardiac surgery, but are rarely required as first-line therapy. Implantable atrial defibrillators are another

nonpharmacologic approach, but substantial patient discomfort and a narrow indication are 2 major disadvantages. Catheter ablation is also an option, and several approaches to this therapy have been reported. Stroke prevention is important for AF patients with a high risk for stroke. Such patients require warfarin (alone or in combination with aspirin) or dabigatran as anticoagulation therapy.
ACC/AHA/ESC 2006 Guidelines. J Am Coll Cardiol. 2006;48:854-906.

The CHADS2 Index

Stroke Risk Score for AF

Score (points) Congestive Heart Failure Hypertension Age > 75 years Diabetes mellitus Stroke or TIA 1 1 1 1 2

Antithrombotic Selection
Factors to Consider
Potential for drug-drug and drug-food interactions Ability to comply with twice-daily dosing (dabigatran) Ability to comply with INR monitoring (warfarin) Patient preferences Costs (drug costs, monitoring costs) Reversibility

Notes: These are important factors to consider when selecting

antithrombotic therapy for patients with AF.
Wann LS et al. J Am Coll Cardiol. 2011;57(11):1330-1337.

Notes: The CHADS2 Index may be used to assess stroke risk

in patients with nonvalvular AF. A patients CHADS2 score can help determine the need for and help guide selection of antithrombotic therapy.

Gage BF et al. JAMA. 2001;285: 2864-2870. Van Walraven C et al. Arch Intern Med. 2003;163:936-934. Nieuwlaat R et al. Eur Heart J. 2006;27:3018-3026.

Etiologies and Factors Predisposing to AF

Atrial pressure elevation
Mitral or tricuspid disease Systemic or pulmonary hypertension Ventricular dysfunction

Atrial Fibrillation and Stroke

Stroke is the most devastating complication of AF AF is an independent risk factor for stroke, even if patient is asymptomatic Stroke risk persists in patients with high-risk profile despite a rhythm control strategy
10 8 6 4 2 0

Annual Stroke Rate (%)

Permanent AF Intermittent AF

Idiopathic or familial (lone AF) Drugs (EtOH, caffeine) Endocrine disorders

Hyperthyroidism

Inflammatory or infiltrative atrial disease

Pericarditis, myocarditis Amyloidosis, age-related fibrosis

Low Risk

Moderate Risk

High Risk

Postoperative
Cardiac, pulmonary, esophageal

Notes: AF is an independent risk factor for stroke; in fact,

Neurogenic
Subarachnoid hemorrhage Nonhemorrhagic, major stroke

Congenital heart disease

Notes: A number of modifiable and non-modifiable
factors may contribute to the development if AF.
Fuster V et al. J Am Coll Cardiol 2006;48:854.

it increases the risk of stroke approximately 5-fold. It is estimated that 15% of all strokes in the United States are attributable to AF, and the proportion increases markedly with age. Additionally, ischemic stroke associated with AF is often more severe than stroke due to other causes. A retrospective study determined that those with AF were more likely than those without AF to be bedridden following a stroke (41.2% vs 23.7%, P<.0005). Finally, asymptomatic, or silent AF, is common and may also increase the risk of stroke. Despite the availability of effective antithrombotic therapies, an estimated 50% of patients with AF and stroke risk markers do not receive anticoagulation therapy, despite the fact that they are eligible for such therapy. Clinicianlevel barriers to effective anticoagulation therapy include: underestimation of warfarin benefit in AF, overutilization of aspirin as a warfarin alternative, and overestimation of patient fall risk. Primary care clinicians may play an essential role in helping to reduce this clinical practice gap.
Slide courtesy of J. Reiffel, MD Fuster V et al. J Am Coll Cardiol. 2006;48(4):e149-e246. Kannel WB et al. Med Clin North Am. 2008;92(1):17-42. Page RL et al. Circulation. 2003;107(8):11411145.Hart RG et al. J Am Coll Cardiol. 2000;35(1):183-187.

Atrial Fibrillation: Key Points

Common disease and increasing in prevalence. Significant consequences: reduced quality of life, increased risk of stroke, mortality. Anticoagulation is essential in AF patients with stroke risk markers; half of patients with AF who are eligible for anticoagulation therapy do not receive it. Primary care practitioners can help to improve diagnosis of AF and decrease stroke risk by facilitating appropriate anticoagulation therapies.

This Non-CME educational program is sponsored in part by Boehringer Ingelheim Pharmaceuticals, Inc.
*Please note: Brochure content is provided by pmiCME and American College of Physicians (ACP)