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Making the Connection: A Call to Action Against Undiagnosed Atrial Fibrillation—Improving Detection, Reducing Risk

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Christian T. Ruff, MD, MPH, prepared useful practice aids pertaining to atrial fibrillation for this CME/CE/CPE activity titled "Making the Connection: A Call to Action Against Undiagnosed Atrial Fibrillation—Improving Detection, Reducing Risk." For the full presentation, monograph, complete CME/CNE/CPE information, and to apply for credit, please visit us at http://bit.ly/2FB4jdU. CME/CNE/CPE credit will be available until March 26, 2021.

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Making the Connection: A Call to Action Against Undiagnosed Atrial Fibrillation—Improving Detection, Reducing Risk

  1. 1. Access the activity,“Making the Connection: A Call to Action Against Undiagnosed Atrial Fibrillation,”at PeerView.com/NTH40 AAFP Updated Guideline on Pharmacologic Management of Newly Detected Atrial Fibrillation1 PRACTICE AID AAFP: American Academy of Family Physicians; AF: atrial fibrillation; CHA2 DS2 -VASc: congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke/transient ischemic attack/ thromboemolic event, vascular disease, age 65 to 74 years, sex category; CHADS2 : congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke/transient ischemic attack/ thromboembolic event; HAS-BLED: hypertension, abnormal renal and liver function, stroke history, bleeding (prior major bleeding or predisposition to bleeding), labile INR, elderly (age >65 years), medication usage predisposing to bleeding and prior alcohol or drug usage history. 1. Hauk L. Am Fam Physician. 2017;96:332-333. Recommendation 1 The AAFP strongly recommends rate control in preference to rhythm control for the majority of patients with AF Preferred options for rate-control therapy include non-dihydropyridine calcium channel blockers and ß-blockers Rhythm control may be considered for certain patients based on symptoms, exercise tolerance, and patient preferences Recommendation 2 The AAFP recommends lenient rate control (<110 bpm at rest) over strict rate control (<80 bpm at rest) for patients with atrial fibrillation Recommendation 3 The AAFP recommends that clinicians discuss the risk of stroke and bleeding with all patients considering anticoagulation Clinicians should consider using the continuous CHADS2 or continuous CHA2DS2-VASc for prediction for risk of stroke and HAS-BLED for prediction of risk for bleeding in patients with AF Recommendation 4 The AAFP strongly recommends that patients with atrial fibrillation receive chronic anticoagulation unless they are at low risk of stroke (CHADS2 <2) or have specific contraindications Choice of anticoagulation therapy should be based on patient preferences and patient history. Options for anticoagulant therapy may include warfarin, apixaban, dabigatran, edoxaban, or rivaroxaban Recommendation 5 The AAFP strongly recommends against dual treatment with anticoagulant and antiplatelet therapy in most patients who have atrial fibrillation Strong recommendation, high-quality evidence Strong recommendation, moderate-quality evidence Weak recommendation, low-quality evidence Good practice point
  2. 2. Access the activity,“Making the Connection: A Call to Action Against Undiagnosed Atrial Fibrillation,”at PeerView.com/NTH40 EHRA Atrial Fibrillation Screening Method and AF-SCREEN Recommended Populations AF: atrial fibrillation; BP: blood pressure; EHRA: European Heart Rhythm Association; ESUS: embolic stroke of undetermined source; PPG: photoplethysmography. 1. Mairesse GH et al. Eurospace. 2017;19:1589-1623. 2. Freedman B et al. Circulation. 2017;135:1851-1867. PRACTICE AID Automated BP measurement Pulse palpation Multi-lead patch recording Handheld ECG devices Implanted devices Smartphone application ECG confirmation • Clinical evaluation • 12-lead ECG • Refer for echocardiogram • Treat underlying heart disease • Assess risk of stroke • Anticoagulation if needed • Rate-control therapy • Rhythm control if needed European Heart Rhythm Association Atrial Fibrillation Screening Method1 AF-SCREEN Screening Recommendations2 Primary care or specialist clinics Non-medical healthcare practitioners: Pharmacy General populations: Various venues Where? People aged ≥65 years Patients aged <65 years + enrichmenta Whom? • Opportunistic pulse then ECG • Single time point: Single-lead ECG • Patient activated ECG (2-week): >75 years old or younger if high risk • Post-stroke ESUS: Long-term continuous Patient-activated devices: Blood pressure/PPG How? AF-SCREEN preferred Possible with further data Clinical screening ECG screening a Use of additional risk factors or biomarkers to increase the proportion with unknown AF in the screened population.
  3. 3. North American Thrombosis Forum (NATF) Anticoagulant Comparison Chart1,a PRACTICE AID Access the activity,“Making the Connection: A Call to Action Against Undiagnosed Atrial Fibrillation,”at PeerView.com/NTH40 Warfarin (Coumadin) Dabigatran (Pradaxa) Rivaroxaban (Xarelto) Apixaban (Eliquis) Edoxaban (Savaysa) Generic? Yes No No No No FDA approval Pre-1982 Warfarin was first used in humans in 1954, before the FDA regulated drugs October 2010 July 2011 December 2012 January 2015 FDA approved for • Stroke prevention in AF and valve replacements • Treatment and prevention of DVT and PE • Stroke prevention in nonvalvular AF • Treatment and secondary prevention of DVT and PE • VTE prevention after hip replacement surgery • Stroke prevention in nonvalvular AF • Treatment and secondary prevention of DVT and PE • VTE prevention after hip and knee replacement surgery • Stroke prevention in nonvalvular AF • Treatment and secondary prevention of DVT and PE • VTE prevention after hip and knee replacement surgery • Stroke prevention in nonvalvular AF • Treatment and secondary prevention of DVT and PE Drug image Available strengths Variable 75-mg, 110-mg, or 150-mg capsule 10-mg, 15-mg, or 20-mg tablet 5-mg or 2.5-mg tablet 15-mg, 30-mg, or 60-mg tablet
  4. 4. North American Thrombosis Forum (NATF) Anticoagulant Comparison Chart1,a a Betrixaban is not approved for treatment of atrial fibrillation. AF: atrial fibrillation; NATF: North American Thrombosis Forum; PE: pulmonary embolism; VTE: venous thromboembolism. 1. https://natfonline.org/wp-content/uploads/2018/01/Anticoagulant-Comparison-Chart-Jan2018.pdf. Accessed April 11, 2018. PRACTICE AID Access the activity,“Making the Connection: A Call to Action Against Undiagnosed Atrial Fibrillation,”at PeerView.com/NTH40 Warfarin (Coumadin) Dabigatran (Pradaxa) Rivaroxaban (Xarelto) Apixaban (Eliquis) Edoxaban (Savaysa) Dosing frequency Once daily Twice daily Once daily Following a 3-week loading period of twice daily for PE and DVT Twice daily Following a 1-week loading period of 10 mg twice daily for PE and DVT Once daily Onset Slow Several days Fast A few hours Fast A few hours Fast A few hours Fast A few hours Kidney function No Yes Kidney function affects the dosage Yes Kidney function affects the dosage Yes Kidney function affects the dosage Yes Kidney function affects the dosage Food effect Yes Speak with your provider about vitamin K intake and warfarin No Yes Rivaroxaban should be taken with dinner No No Drug interactions Many Few Few Few Few Routine lab monitoring Yes No No No No Reversal agents Yes Vitamin K, fresh frozen plasma, prothrombin complex concentrates Yes Idarucizumab Yes Coagulation factor Xa (recombinant), inactivated-zhzo [andexanet alfa] Yes Coagulation factor Xa (recombinant), inactivated-zhzo [andexanet alfa] Soon May use prothrombin complex concentrates in emergencies
  5. 5. Atrial Fibrillation Screening: Risk Calculators, Tools, and Additional Resources PRACTICE AID Access the activity,“Making the Connection: A Call to Action Against Undiagnosed Atrial Fibrillation,”at PeerView.com/NTH40 Risk Factor Points CHF 1 Hypertension 1 Age ≥75 years 1 Diabetes mellitus 1 Stroke/TIA/embolism 2 Maximum score 6 Risk Factor Points CHF/LV dysfunction 1 Hypertension 1 Age ≥75 years 2 Diabetes mellitus 1 Stroke/TIA/embolism 2 Vascular disease 1 Age 65-74 years 1 Sex category (female) 1 Maximum score 9 Clinical Characteristic Points H Hypertension 1 A Abnormal liver and/or renal function 1 each; max. of 2 S Stroke 1 B Bleeding 1 L Labile INR 1 E Elderly (age >65) 1 D Drugsa and/or alcohol 1 each; max. of 2 Maximum score 9 CHADS2 Risk Score for Prediction of Stroke Risk in AF CHA2DS2-VASc Risk Score for Prediction of Stroke Risk in AF HAS-BLED Risk Calculator for Predicting Risk of Bleeding With Anticoagulation Additional Resources for Physicians • NATF Atrial Fibrillation Action Initiative • NATF AF Action Initiative Document • Arrhythmia Alliance Homepage • Arrhythmia Alliance “AF and How AF Causes Stroke” (video) • AAFP Clinical Practice Guideline on Atrial Fibrillation a Aspirin/NSAIDs.
  6. 6. Atrial Fibrillation Screening: Risk Calculators, Tools, and Additional Resources AAFP: American Academy of Family Physicians; AF: atrial fibrillation; BP: blood pressure; CHA2 DS2 -VASc: congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke/transient ischemic attack/thromboemolic event, vascular disease, age 65 to 74 years, sex category; CHADS2 : congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke/transient ischemic attack/thromboembolic event; HAS-BLED: hypertension, abnormal renal and liver function, stroke history, bleeding (prior major bleeding or predisposition to bleeding), labile INR, elderly (age >65 years), medication usage predisposing to bleeding and prior alcohol or drug usage history; INR: International Normalized Ratio; LV: left ventricular; NATF: North American Thrombosis Forum. 1. www.afscreen.org. Accessed March 30, 2018. 2. Chan P-H et al. J Am Heart Assoc. 2016;5:e003428. PRACTICE AID Access the activity,“Making the Connection: A Call to Action Against Undiagnosed Atrial Fibrillation,”at PeerView.com/NTH40 Screening Tools for Atrial Fibrillation1,2 Radial pulse measurement Insertable cardiac monitor BP monitor Smartphone-based heart rate monitor Home heart rate monitor Heart rate monitor patch

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