Atrial FibrillationDetection in the Community and

Hospital settingsShuja Punekar

Consultant Cerebrovascular Physician Hon Senior Lecturer, Manchester

Medical School

• How common is AF in the population• Permanent vs Paroxysmal AF• Subclinical forms of AF and risk of stroke• Are there certain groups of patients or

certain areas where we may find more than the usual number of AF patients?

• How can we improve identifying all patients with AF?

•What do the 3 slides show

•What is the unifying pathology

Prevalence of AF by age groups in the Rotterdam study

European Heart Journal (2006) 27, 949–953

Prevalence of AF in ScotlandAge and sex specific figures from the Renfrew‐

Paisley study from the West of Scotland. Note this study does not include patients 65 years of age or 

older 

Heart 2001;86:516–521

Approximate Prevalence of AF by age groups

Life Time Risk of AF at age 55Is approx

European Heart Journal (2006) 27, 949–953

Men

23.8%

Women

22.2%

1 in 4

Clinical Predictors for AF from the Renfrew‐Paisley study 

Systolic BPOdds ratio 2.1 for SBP >/= 169 mm Hg

CardiomegalyOn CXR; Odds ratio 14

Heart 2001;86:516–521

Permanent AF

Paroxysmal AF

Subclinical AF

NICE recommends anticoagulation for eligible patients whether they have permanent or paroxysmal AF

Sub‐clinical AFSub‐clinical tachyarrhythmias were associated with an increased risk of Clinical AF and of 

Ischaemic Stroke and systemic thromboembolism

N Engl J Med 2012;366:120-9.

Warfarinreduces Stroke risk by

62%Aspirin

reduces Stroke risk by

22%

NNT• NNT to prevent 1 stroke per year of anticoagulation therapy in

secondary prevention (ARR: 8.5%) = 12

• NNT in primary prevention = 37

HEARTJNL/2005/066944

NNT for Secondary Prevention

= 12

NNT for Primary

Prevention = 37

How good are we in achieving target INR in patients on warfarin

In most RCTs we see ‘Time in Therapeutic Range’ (TTR) to be between 60 – 70 % as demonstrated here for AF patients on oral

anticoagulation.

Circ Cardiovasc Qual Outcomes 2008;1;84-91;

Time in therapeutic range (TTR) predicts adverse outcomes – both thromboembolic and haemorrhagic in AF patients on oral anticoagulation (weighted sample sizes); p values were significant for retrospective studies and not RCTs; Graph shows all studies - big circles are mostly RCTs

Circ Cardiovasc Qual Outcomes 2008;1;84-91;

Risk of Intracranial haemorrhage rises steeply for INRs over thetherapeutic range (Q J Med 2011; 104:747–760)

Improving Detection of AF in Hospitals

Acute Hospitals offer a great opportunity to detect almost all patients with AF and commence 

adequate antithrombotic/anticoagulant 

therapy

PrevalencePrevalence of AF in Acute Medical admissions in Preston500 consecutive acute medical admissions at RPH were screened for AF

50 years of age or over between 11 May and 1 June 2010

102 had AF; Prevalence = 20.4%59% were F and 41% MMean age was 78

Lucy Freeman, Shuja Punekar. 2010Awarded best student oral presentation at the UK Stroke Conference Nov/Dec 2010

5

19

40

1519

2 00

10

20

30

40

0 1 2 3 4 5 6

Spread of CHADS2 scores

No

>75% of AF patients from the medical admissions study scored 2 or more 

on CHADS2Lucy Freeman, Shuja Punekar. 2010

Type of AF Number of patients

New onset 26

Permanent 57

Paroxysmal 16

Persistent 1

Lucy Freeman, Shuja Punekar. 2010

5040

1005

101520253035404550

Warfarin Aspirin+ None

As many as 50% of patients were discharged only on Aspirin or no antithrombotic therapy at all

Lucy Freeman, Shuja Punekar. 2010

Improving Detection of AF the Community

Opportunistic Screening

• Take a pulse– For eg on all patients attending Flu

vaccinations at your practice and then confirm AF with an ECG if the pulse is irregular

• Colchester PBC Group incentivised 37 practices out of 43 to carry out screening of patients at Flu clinics for AF.

• These 37 practices screened 34,201 patients in six weeks, detecting 189 new patients with AF. The project prevented an estimated five strokes, representing an annual saving of £220,000 – a 322 per cent return on investment in addition to improved quality outcomes.

5 August 2010 Health Service Journal 25

AF in Care Homes

AF in Care HomesStudy Carried out in Care homes in Preston(May-June 2011)

McCrory S, Punekar SN; 2011

0

13.33 12.7718.58

26

66.66

0

10

20

30

40

50

60

70

51-60 61-70 71-80 81-90 91-100 100-110

Prevalence of AF in RH/NH homes by age groups

AF%

AF in Nursing/Care Homes StudyPrevalence of AF was similar to that found in other studies on the general population.

McCrory Simon, Punekar Shuja. Unpublished data

AF in the hospitalised elderly

A cross sectional survey was carried out at RPH on the 30th Jan 2012 and all elderly patients 75 years of age or over admitted in 4 medical wards were assessed for presence of AF 

and their CHADS2 scores 

Total No of patients 55

Mean age 85 years

Male/Female 25/30 45%/55%

Patients with AF 22 40%

Patients with AF & CHADS2 score of 2 or more

19 86.4%

40% of hospitalised elderly(75+yrs) were in AF and nearly 90% of those had a CHADS2 score 

of 2 or above

Learning points

Hospitalised elderly (75+) have a very high risk of being in AF – 40%

Hospitalised elderly patients with AF invariably have high CHADS2 scores

Turning the CHADS2 on it’s head and using it to detect AF instead 

Those who had a CHADS2 score of 2 or more were more likely to have AF vs those whose CHADS2 was <2  

(48.72% vs 18.75% ) 

Is there evidence that we can improve outcomes by managing

the risk factors

Lancet 2004; 363: 1925–33

•Age-specific incidence rates of non-minor Stroke in the OCSP(1981) and the Oxvasc(2004) studies in Oxford showing a significant decline•As shown here the incidence of Stroke is improving in the general population

Age-standardized mortality rates in the Oxford region 1979 to 2004 (with 95% confidence intervals) and England 1996 to 2004,comparing underlying cause and mentions.‘Underlying cause’ as mentioned in the death certificate; ‘Mentions’ = any mention on the death certificate

Stroke. 2008;39:2197-2203.

Stroke Mortality is Falling in England

CVD Mortality - rate /000 popn - All persons under 75

0

50

100

150

200

250

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Chorley

Preston

South Ribble

West Lancashire

Central Lancashire

England

Source: Central Lancs PCT Data includes Stroke, IHD and all cardiovascular causesPer 100,000 population

Cardiovascular and Stroke Mortality in Lancashire

Why is the incidence of Stroke (and CV disease) improving

Premorbid medication inIncident first-ever TIA or Stroke in the OCSC and OxVasc studies – Note the rise in allMedications.(Primary prevention is in patients with no previous evidence of vascular disease.)

Lancet 2004; 363: 1925–33

We are managing risk factors much better now

Thank you