Prevention of Atrial Prevention of Atrial FibrillationFibrillation

Karin Prussak, DNP, ARNPKarin Prussak, DNP, ARNP

Florida ACCFlorida ACC

August 17, 2013August 17, 2013

ObjectivesObjectives

1.1. Evaluate the economic burden of AF Evaluate the economic burden of AF

2.2. List the most common risk factors of AF.List the most common risk factors of AF.

3.3. Identify risk factor modification to Identify risk factor modification to decrease risk of AF based on current decrease risk of AF based on current research studies.research studies.

4.4. Apply EBP to decrease risk of AFApply EBP to decrease risk of AF

Healthy People 2020Healthy People 2020

For 3 decades, Healthy People has established For 3 decades, Healthy People has established benchmarks and monitored progress over time benchmarks and monitored progress over time in order to:in order to: Encourage collaborations across sectors. Encourage collaborations across sectors. Guide individuals toward making informed health Guide individuals toward making informed health

decisions. decisions. Measure the impact of prevention activities. Measure the impact of prevention activities.

http://www.healthypeople.gov/2020/about/default.aspx

What Are Some of the Main Objectives of Health What Are Some of the Main Objectives of Health Care Reform Legislation? Care Reform Legislation?

H.R. 3962 authors project that 96% of the U.S. population will have health coverage under theH.R. 3962 authors project that 96% of the U.S. population will have health coverage under thelegislation, which includes an optional public insurance programlegislation, which includes an optional public insurance programH.R. 3590 authors project that 94% of the U.S. population will have health coverage and does not H.R. 3590 authors project that 94% of the U.S. population will have health coverage and does not include a public insurance optioninclude a public insurance option

Reform the health care insurance system by eliminating pre-existing conditions, mandating coverage of Reform the health care insurance system by eliminating pre-existing conditions, mandating coverage of certain conditions, capping out-of-pocket expenditures, creating health insurance exchanges, etc.certain conditions, capping out-of-pocket expenditures, creating health insurance exchanges, etc.

Revising various Medicare ProgramsRevising various Medicare Programs Expanding Medicaid ProgramsExpanding Medicaid Programs Ensure an adequate workforce to meet current and future population needsEnsure an adequate workforce to meet current and future population needs Expand health care services in medically underserved areas, including schoolsExpand health care services in medically underserved areas, including schools Cost reductions/Health care delivery advancementsCost reductions/Health care delivery advancements

information technology (IT) advancementsinformation technology (IT) advancements improving the quality of care using evidenced-based protocolsimproving the quality of care using evidenced-based protocols pricing transparencypricing transparency supporting prevention and chronic care managementsupporting prevention and chronic care management boosting public health infrastructureboosting public health infrastructure emphasizing personal responsibilityemphasizing personal responsibility

http://www.cherokee.org/docs/Services/Health/Health_Care_Reform_QA_revised.pdf

Epidemiology of AFEpidemiology of AF

AF has become an epidemic in the United AF has become an epidemic in the United States and world wide:States and world wide: ““An outbreak or product of sudden rapid An outbreak or product of sudden rapid

spread, growth or development.”spread, growth or development.” Over 5 million people have AF at this time Over 5 million people have AF at this time

and this is expected to increase to over and this is expected to increase to over 12 12 million in the next 20 yearsmillion in the next 20 years..

Lip, Kakar & Watson, 2007; Go, et al., 2001; Chen & Shen, 2007.

Incidence Per Age GroupIncidence Per Age Group

EpidemiologyEpidemiology Lifetime risk of developing AF in individuals over 40 is Lifetime risk of developing AF in individuals over 40 is

one in 4.one in 4. AF is seen in 1% of the population and the prevalence in AF is seen in 1% of the population and the prevalence in

adults under 55 is 0.1% and 9% in octogenarians.adults under 55 is 0.1% and 9% in octogenarians. Prevalence increases with the severity of heart failure or Prevalence increases with the severity of heart failure or

valvular heart disease.valvular heart disease. Occurs more often in men than women.Occurs more often in men than women. Accounts for 34.5% of all patients hospitalized for Accounts for 34.5% of all patients hospitalized for

arrhythmia.arrhythmia. Transient AF can occur in 15-40% of CV surgery Transient AF can occur in 15-40% of CV surgery

patients.patients.

Fuster, V., et al. (2001). ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation. Circulation, 104, 2120.

Economic Burden of AFEconomic Burden of AF

$6.65$6.65 billion in total treatment costs: billion in total treatment costs:

Hospital: Hospital: $4.88$4.88 billion billion Outpatient: Outpatient: $1.53$1.53 billion billion Medications: Medications: $235$235 million million

Coyne, et al. (2006).

CostCost

Not only is AF an economic burden to the Not only is AF an economic burden to the citizens of the US, but the secondary citizens of the US, but the secondary effects of AF are also costly:effects of AF are also costly: StrokeStroke DisabilityDisability Tachycardia induced heart failureTachycardia induced heart failure Heart failureHeart failure Decreased quality of lifeDecreased quality of life

Significance of ProblemSignificance of Problem

Overall risk of developing AF is rising.Overall risk of developing AF is rising. Increasing prevalence and incidence of AFIncreasing prevalence and incidence of AF Disabling co-morbid conditions such as heart failure, Disabling co-morbid conditions such as heart failure,

CHF, stroke, depression, anxiety and other arrhythmias.CHF, stroke, depression, anxiety and other arrhythmias. Medical and interventional treatments are available but Medical and interventional treatments are available but

are not without risk, adverse effects and do not cure AF are not without risk, adverse effects and do not cure AF or decrease mortality or morbidity.or decrease mortality or morbidity.

80% of subjects which present with AF have at least one 80% of subjects which present with AF have at least one risk factorrisk factor..

Lloyd-Jones et al. 2004; Ruigomez, Johannson, Wallander & Rodriguez 2002.

So….So….

Despite the aging population, history of Despite the aging population, history of CHF, MI and hypertension, CHF, MI and hypertension, these factors these factors alone are not sufficient to explain the alone are not sufficient to explain the growing incidence of AF.growing incidence of AF.

Known Risk Factors of AFKnown Risk Factors of AF

HypertensionHypertension Advancing AgeAdvancing Age Valvular Disease (RHD)Valvular Disease (RHD) HyperthyroidismHyperthyroidism CardiomyopathyCardiomyopathy Heart FailureHeart Failure Coronary Artery DiseaseCoronary Artery Disease Diabetes MellitusDiabetes Mellitus SepsisSepsis

ObesityObesity Obstructive Sleep ApneaObstructive Sleep Apnea Metabolic SyndromeMetabolic Syndrome Genetic predispositionGenetic predisposition Cardiothoracic surgery: Cardiothoracic surgery:

CABG and valvular CABG and valvular surgerysurgery

Previous episodes of AFPrevious episodes of AF Esophageal resectionEsophageal resection

Wu et al., 2005; Chen & Shen, 2007; Gami et al., 2007; Lip et al., 2007; Watanabe et al., 2008; Fuster et al., 2006; Otway, Vandenburg & Fatkin, 2007.

Can we prevent AF?Can we prevent AF?

Primary prevention of AFPrimary prevention of AF Focus on modifiable risk factors:Focus on modifiable risk factors:

ObesityObesity OSAOSA HypertensionHypertension HyperthyroidismHyperthyroidism Heart failureHeart failure Metabolic SyndromeMetabolic Syndrome Cardiothoracic surgeryCardiothoracic surgery

Develop prevention/risk reduction strategies to reduce Develop prevention/risk reduction strategies to reduce risk of primary and secondary AF.risk of primary and secondary AF.

Pathophysiology of AFPathophysiology of AF Atrial fibrosis and loss of Atrial fibrosis and loss of

muscle massmuscle mass

Expression of angiotension-Expression of angiotension-converting enzyme increased converting enzyme increased 3-fold during persistent AF3-fold during persistent AF

Increase in left ventricular Increase in left ventricular hypertrophy led to increase in hypertrophy led to increase in left atrial dimension which left atrial dimension which increases the risk of AFincreases the risk of AF

Atrial stretch can cause AF Atrial stretch can cause AF and AF can cause atrial and AF can cause atrial dilationdilation

InflammationInflammation Autonomic Nervous System Autonomic Nervous System

activityactivity Atrial ischemiaAtrial ischemia LV diastolic dysfunction affects LV diastolic dysfunction affects

stretch receptors in the stretch receptors in the pulmonary veins or directly pulmonary veins or directly affects atrial myocardium.affects atrial myocardium.

http://www.hrsonline.org/Policy/ClinicalGuidelines/upload/AFGuidelinesFullText.pdf

AF Risk Factor Causal ModelAF Risk Factor Causal Model

ObesityOverweight

Hypertension

Heart Failure

Increased Left Atrial Diameter (LAD)

Left Ventricular Enlargement or Hypertrophy

New Onset Atrial Fibrillation

Prussak, K. (2008). Prevention of New-Onset Atrial Fibrillation.

GeneticsGenetics

Increased relative risk of 1.85% in Increased relative risk of 1.85% in offspring of one or both parents with AFoffspring of one or both parents with AF

Cannot change geneticsCannot change genetics Offspring should be evaluated for Offspring should be evaluated for

increased risk of AFincreased risk of AF

Fuster, et al. 2006.

Increasing AgeIncreasing Age

Increased prevalence with increasing age.Increased prevalence with increasing age. Risk higher in men, but women are now Risk higher in men, but women are now

living longer, which places a larger living longer, which places a larger population at risk for AF.population at risk for AF.

Cannot change risk of age, only risk Cannot change risk of age, only risk reduction of other risk factors.reduction of other risk factors.

ObesityObesity The CDC defines adults as The CDC defines adults as overweightoverweight if the if the

Body Mass Index (BMI) is Body Mass Index (BMI) is 25-29.925-29.9 and and obeseobese as as BMI BMI >> 30 30..

In 2006, prevalence of obesity in males was In 2006, prevalence of obesity in males was 33.3% and 35.3% in women.33.3% and 35.3% in women.

72 million Americans are obese and adults aged 72 million Americans are obese and adults aged 40-59 have the highest prevalence of all age 40-59 have the highest prevalence of all age groups.groups.

Prevalence of obesity in Florida is reported to be Prevalence of obesity in Florida is reported to be 23.6%23.6%

http://www.bodyshapingtips.com/images/BMI-Chart.png

Obesity and AFObesity and AF

Risk of AF increased 5% Risk of AF increased 5% for each one unit increase for each one unit increase in BMI.in BMI.

Significant difference noted Significant difference noted in LAD in obese men in LAD in obese men compared to overweight compared to overweight men (p<.001).men (p<.001).

Increased risk of AF with Increased risk of AF with increased LAD and LVH.increased LAD and LVH.

Wang, T. et al.JAMA, 2004; Pritchett, A. et al.J Am Coll Cardiol, 2003; Frost, Hune & Vestergaard, Am J Med, 2005;Ruigomez,,A. et al.,J Am Epidem, 2002; Gami, A. et al., J Am Coll Cardiol, 2004.

Obstructive Sleep Apnea (OSA)Obstructive Sleep Apnea (OSA)

OSA affects 17-24% of adults OSA affects 17-24% of adults and is present in 40-90% of and is present in 40-90% of overweight and obese overweight and obese subjects.subjects.

A retrospective cohort study by A retrospective cohort study by Gami et al. (2007) followed Gami et al. (2007) followed 3542 subjects for 4.7 years 3542 subjects for 4.7 years and revealed that BMI and and revealed that BMI and OSA are both strong OSA are both strong predictors of AF together and predictors of AF together and independentlyindependently..

Kanagala, R., et al. (2003). Circulation; Gami, A., et al. (2007). J Am Coll Cardiol

HypertensionHypertension

Double-blind randomized Double-blind randomized study of 8831 pts with study of 8831 pts with HTN.HTN.

Received losartan and Received losartan and atenolol.atenolol.

Assessed LV sizeAssessed LV size 12.4% lower risk of AF 12.4% lower risk of AF

with decrease in LV size with decrease in LV size (Cornwell product) (Cornwell product)

Okin, P., et al.(2006). JAMA.

Heart FailureHeart Failure

The prevalence of AF in patients with HF The prevalence of AF in patients with HF ranges from 10 to 30%ranges from 10 to 30%

This has been observed to increase in This has been observed to increase in proportion to the severity of HF from <10% proportion to the severity of HF from <10% in those with New York Heart Association in those with New York Heart Association (NYHA) functional class I HF to (NYHA) functional class I HF to approximately 50% in those with NYHA approximately 50% in those with NYHA functional class IV. functional class IV.

Maisel, W. et al. (2003). Am J Cardiol; Stevenson, S., et al. (1999). N Engl J Med.

SOLVD TrialSOLVD Trial

Retrospective analysis revealed after 2.9 Retrospective analysis revealed after 2.9 years of follow-up, 5.4% of patients years of follow-up, 5.4% of patients receiving enalapril vs. 24% in placebo receiving enalapril vs. 24% in placebo group developed AF.group developed AF.

Vermes, E., et al. (2003). Circ.

HyperthyroidismHyperthyroidism

Increases risk of developing AFIncreases risk of developing AF Thyroid hormone influences arrhymogenic Thyroid hormone influences arrhymogenic

activity of atrial myocytes.activity of atrial myocytes. AF occurs in 10-15% of patients with AF occurs in 10-15% of patients with

hyperthyroidism.hyperthyroidism. Treat with thyroxine and beta blockers Treat with thyroxine and beta blockers Treatment results in conversion to sinus rhythm Treatment results in conversion to sinus rhythm

is 2/3 of patients.is 2/3 of patients.

Jayaprasad, N. & Johnson, F. (2005). Indian Pacing Electrophysiol J.

Metabolic SyndromeMetabolic Syndrome

National Cholesterol Education Program National Cholesterol Education Program defined MS if at least 3 of the following defined MS if at least 3 of the following factors are met:factors are met: Elevated BMIElevated BMI Elevated triglyceridesElevated triglycerides Low HDLLow HDL Increased BPIncreased BP Impaired glucose toleranceImpaired glucose tolerance

NCEP-ATP III

Metabolic Syndrome and AFMetabolic Syndrome and AF

28,449 Japanese subjects followed for a mean 28,449 Japanese subjects followed for a mean of 4.5 years in a prospective study. of 4.5 years in a prospective study.

AF developed in 265 participantsAF developed in 265 participants All components except for high triglycerides All components except for high triglycerides

contributed to the development of AFcontributed to the development of AF 3 or more components of MS revealed a HR of 3 or more components of MS revealed a HR of

3.27 and obesity and elevated BP contributed 3.27 and obesity and elevated BP contributed substantially to increased risk of AF.substantially to increased risk of AF.

Watanabe, H., et al. (2008). Circ.

Predictors of Post-op AFPredictors of Post-op AF Advanced ageAdvanced age Male genderMale gender DigoxinDigoxin Peripheral arterial diseasePeripheral arterial disease Chronic lung diseaseChronic lung disease Valvular heart diseaseValvular heart disease Left atrial enlargementLeft atrial enlargement Previous cardiac surgeryPrevious cardiac surgery Discontinuation of beta-blocker medicationDiscontinuation of beta-blocker medication Preoperative atrial tachy-arrhythmiasPreoperative atrial tachy-arrhythmias PericarditisPericarditis Elevated postoperative adrenergic toneElevated postoperative adrenergic tone

Creswell, et al. (1993)

Prevention of Peri-operative AFPrevention of Peri-operative AF BMI >30.1 predicts increased risk of AFBMI >30.1 predicts increased risk of AF Post-operative amiodarone decreased risk of AF Post-operative amiodarone decreased risk of AF

from 47% to 35%from 47% to 35% Beta blockers protected against AFBeta blockers protected against AF Statin therapy pre-op not associated with Statin therapy pre-op not associated with

decreased incidence of AFdecreased incidence of AF Sotalol was found to be more effective in Sotalol was found to be more effective in

reducing AF than beta blockers or placebo.reducing AF than beta blockers or placebo. PUFA’s lower risk of AF post CABGPUFA’s lower risk of AF post CABG AF is self-limitingAF is self-limiting IV Magnesium SulfateIV Magnesium Sulfate

Fuster, et. al. (2006); Calo, et al. (2005); Saravannan et al. (2009).

Polyunsaturated Fatty Acids Polyunsaturated Fatty Acids and AF (PUFA)and AF (PUFA)

ReferenceReference Study DesignStudy Design SubjectsSubjects ConclusionConclusionPhysician Health Study Physician Health Study ProspectiveProspective 17679 pts17679 pts AF risk higher in PUFA group AF risk higher in PUFA group

Danish StudyDanish Study ProspectiveProspective 47949 pts 47949 pts Stat. insignificant Stat. insignificant

Rotterdam StudyRotterdam Study ProspectiveProspective 5184 pts5184 pts Stat. insignificantStat. insignificant

Mozaffarian et al Mozaffarian et al ProspectiveProspective 4815 pts 4815 pts 28% lower AF risk in 28% lower AF risk in broiled/baked fish groupbroiled/baked fish group

Calo et al. Calo et al. ProspectiveProspective 160 CABG 160 CABG AF risk lower in PUFA group AF risk lower in PUFA group

Saravanan et al Saravanan et al ProspectiveProspective CABG pts CABG pts AF risk lower in PUFA group AF risk lower in PUFA group

Aizer, A. et al., Heart Rhythm, 2006; Brouwer, I., et al., Am Heart J, 2006; Calo, L., et al., J Am Coll Cardiol, 2005; Frost, L., et al., Am J.Clin Nutr, 2005; Mozaffarian, D. et al. Circ, 2004; Saravanan, P., et al., Heart Rhythm, 2009.

Vitamin CVitamin C

Anti-oxidant and Anti-inflammatoryAnti-oxidant and Anti-inflammatory

ReferenceReference SubjectsSubjects ConclusionConclusion

Carnes et al.Carnes et al.

Vit C before and 5 Vit C before and 5 days after CABGdays after CABG

43 pts43 pts 16.3% vs. 39% 16.3% vs. 39% developed AFdeveloped AF

Korantzopoulos et al.Korantzopoulos et al.

2g Vit C 12 hr prior to 2g Vit C 12 hr prior to CV and 500 mg BID CV and 500 mg BID for one week after CVfor one week after CV

44 pts44 pts 4.5% vs. 36.3% 4.5% vs. 36.3% developed AF after 1 developed AF after 1 weekweek

Carnes, C. et al. (2001). Circ; Korantzopoulos, P. et al.(2005). Int J Card.

Statin TherapyStatin Therapy

Pellegrini, et al. (HERS study) studied Pellegrini, et al. (HERS study) studied 2763 postmenopausal women with heart 2763 postmenopausal women with heart disease randomized to HRT or placebo.disease randomized to HRT or placebo.

Data revealed 55% decrease in AF Data revealed 55% decrease in AF incidence compared to women not taking incidence compared to women not taking statinsstatins

65% decrease in prevalence of AF in 65% decrease in prevalence of AF in statin therapy subjects.statin therapy subjects.

Pellegrini, C., et al. Heart Rhythm Society (HRS) Annual Scientific Sessions; May 14-17, 2008,

Statins: Meta-analysisStatins: Meta-analysis

6 studies with total 3,557 subjects in sinus rhythm.6 studies with total 3,557 subjects in sinus rhythm. 3-studies with use of statins in PAF or persistent AF prior to CV; 3-studies with use of statins in PAF or persistent AF prior to CV; 3 studies with primary prevention of AF in patients undergoing 3 studies with primary prevention of AF in patients undergoing

CABG or post MI.CABG or post MI. Use of statins was significantly associated with decreased Use of statins was significantly associated with decreased

risk of AF compared to controls (odds ratio 0.39).risk of AF compared to controls (odds ratio 0.39). Benefit of statin therapy increased in secondary prevention Benefit of statin therapy increased in secondary prevention

of AF than new-onset or post-op AF (OR 0.60).of AF than new-onset or post-op AF (OR 0.60). * Use of statins was significantly associated with * Use of statins was significantly associated with

decreased risk of incidence or recurrence of AF in pts in decreased risk of incidence or recurrence of AF in pts in sinus rhythm with history of AF, undergoing cardiac sinus rhythm with history of AF, undergoing cardiac surgery or AMI.surgery or AMI.

Fauchier, L., et al. (2008). J Am Coll Cardiol.

““Upstream Therapies”Upstream Therapies”

““Refers to the use of non-anti-arrhythmic drugs which modify the atrial Refers to the use of non-anti-arrhythmic drugs which modify the atrial substrate, or target-specific mechanisms of AF to prevent the substrate, or target-specific mechanisms of AF to prevent the occurrence or recurrence of arrhythmia”. occurrence or recurrence of arrhythmia”.

ACEIACEI Beta BlockersBeta Blockers ARBARB PUFAPUFA Vitamin CVitamin C StatinsStatins

Although some retrospective and small study results in selected Although some retrospective and small study results in selected categories have been positive, larger prospective studies have categories have been positive, larger prospective studies have generated controversial and mostly negative results.generated controversial and mostly negative results.

Results remain inconclusive.Results remain inconclusive.

Savelieva, I., et al. (2011). Europace.

Previous Episode of AF and Previous Episode of AF and Secondary PreventionSecondary Prevention

““Atrial fibrillation Atrial fibrillation begets atrial begets atrial fibrillation”fibrillation”

Wann, L.S., et al. (2011). 2011 ACCF/AHA/HRS Focused Update on the Management of Patients With Atrial Fibrillation (Updating the 2006 Guideline).

Recommendations?Recommendations?

Maintain lower BMIMaintain lower BMI Control BPControl BP Treat OSATreat OSA Treat abnormal thyroid functionTreat abnormal thyroid function ACEI, ARB and BB for hypertension and heart ACEI, ARB and BB for hypertension and heart

failure (jury is still out…)failure (jury is still out…) Consider PUFA, Vitamin CConsider PUFA, Vitamin C Preoperative prophylaxisPreoperative prophylaxis

Case Study #1Case Study #1

Mr. P is a 75 year old male with a BMI of Mr. P is a 75 year old male with a BMI of 29, hypertension, normal TSH, no family 29, hypertension, normal TSH, no family history of AF and snores with apneic history of AF and snores with apneic episodes.episodes.

Echo reveals LVH, left atrial dimension of Echo reveals LVH, left atrial dimension of 49 mm, EF of 51% and mild MVR.49 mm, EF of 51% and mild MVR.

How can his health care provider lower his How can his health care provider lower his risk of AF?risk of AF?

Case Study #2Case Study #2

Mrs. R is a 52 year old female with chronic Mrs. R is a 52 year old female with chronic diastolic heart failure, TSH of 0.01, mother diastolic heart failure, TSH of 0.01, mother with persistent AF and being prepared to with persistent AF and being prepared to undergo CV surgery for MV replacement.undergo CV surgery for MV replacement.

How can you decrease this patient’s risk How can you decrease this patient’s risk for AF?for AF?

Evaluation /SuggestionsEvaluation /Suggestions

Lack of studies which focus on prevention of new-onset Lack of studies which focus on prevention of new-onset AF strategies with modifiable risk factorsAF strategies with modifiable risk factors

New directed approaches for prevention of AF are New directed approaches for prevention of AF are necessary to halt this every-increasing public health necessary to halt this every-increasing public health crisis. crisis.

Implementing AF risk reduction strategies aimed at Implementing AF risk reduction strategies aimed at modifiable risk factors such as obesity, OSA, modifiable risk factors such as obesity, OSA, hypertension, heart failure and pre-operative hypertension, heart failure and pre-operative interventions interventions maymay impact the escalating incidence of AF impact the escalating incidence of AF in the population and will ultimately decrease the in the population and will ultimately decrease the healthcare burden of associated co-morbidities of AF. healthcare burden of associated co-morbidities of AF.