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CME / ABIM MOC

Navigating Complexities of Atrial Fibrillation in the Clinic: From Undiagnosed to Early Detection and Treatment

  • Authors: Christian T. Ruff, MD, MPH
  • CME / ABIM MOC Released: 1/20/2023
  • Valid for credit through: 1/20/2024
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for an audience of cardiologists, primary care physicians, emergency medicine physicians, nurse practitioners, and physician assistants that manage patients with, and at risk for, AF.

The goal of this activity is for learners to be better be able to detect AF using evidence-based tools and strategies to initiate earlier detection of AF in clinical practice to facilitate timely diagnosis and appropriate guideline-directed stroke prevention strategies.

Upon completion of this activity, participants will:

  • Demonstrate improved performance associated with the
    • Use of evidence-based screening modalities for AF in accordance with guideline recommendations
    • Selection of appropriate thromboprophylaxis for stroke prevention in patients with AF in accordance with evidence-based guideline recommendations
  • Demonstrate greater confidence in their ability to
    • Accurately detect AF in clinical practice using evidence-based screening technologies


Disclosures

Medscape, LLC requires every individual in a position to control educational content to disclose all financial relationships with ineligible companies that have occurred within the past 24 months. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated. Others involved in the planning of this activity have no relevant financial relationships.


Faculty

  • Christian T. Ruff, MD, MPH

    Associate Professor of Medicine
    Harvard Medical School
    Director of General Cardiology
    Brigham and Women's Hospital
    Senior Investigator
    TIMI Study Group
    Boston, Massachusetts

    Disclosures

    Christian T. Ruff, MD, MPH, has the following relevant financial relationships: 
    Consultant or advisor for: Anthos Therapeutics; Bayer; Boehringer Ingelheim Pharmaceuticals, Inc.; Bristol Myers Squibb Company; Daiichi Sankyo, Inc.; Janssen; Pfizer, Inc.
    Research funding from: Anthos Therapeutics; AstraZeneca Pharmaceuticals LP; Boehringer Ingelheim Pharmaceuticals, Inc.; Daiichi Sankyo, Inc.

Editor

  • Anne M. Sendaydiego, PharmD

    Medical Education Director, WebMD Global, LLC

    Disclosures

    Anne M. Sendaydiego, PharmD, has no relevant financial relationships

Compliance Reviewer

  • Leigh Schmidt, MSN, RN, CNE, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Leigh Schmidt, MSN, RN, CNE, CHCP, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has no relevant financial relationships.


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    For Physicians

  • Medscape, LLC designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Aggregate participant data will be shared with commercial supporters of this activity.

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CME / ABIM MOC

Navigating Complexities of Atrial Fibrillation in the Clinic: From Undiagnosed to Early Detection and Treatment

Authors: Christian T. Ruff, MD, MPHFaculty and Disclosures

CME / ABIM MOC Released: 1/20/2023

Valid for credit through: 1/20/2024

processing....

Case Study, Part 1

Clinician: Hello Margaret. It’s good to see you again.

Patient: Hi Dr Williams. Please call me Marge. All my friends do and I’ve been coming here long enough now.

Clinician: Yes, of course. So Marge, how are your cats doing? The last time I saw you I believe you just got a second kitten.

Patient: You’re right, see I knew we were on a nickname basis. Boots is fitting right in and is claiming her territory. And she’s not just taking over Milly’s space, but mine too! She always wants to snuggle my feet at bedtime.

Clinician: Well, she sounds like a friendly addition. So, I see it’s been about 8 months since your last visit, so you’re coming in a little bit early. Has something been going on?

Patient: You know, I just don’t feel well overall. I’m not sure if I am retaining fluid again, but I thought that was under control. I just feel more tired than usual and a bit out of it. The labs from my primary doctor seemed to be ok, so I thought I should see you too.

Clinician: That was a good idea. I see your heart rate is higher than usual and you do have a history of mild heart palpitations. Does it ever feel like your heart is beating fast in your chest?

Patient: Actually, I have been noticing that again. And I need to sit down sometimes almost like I’m winded, even if I’m not doing much.

Clinician: I see! So, it seems like you might be experiencing some shortness of breath too?

Patient: Yea I guess I am.

Clinician: Can you tell me how often you feel this way? And how long it lasts?

Patient: In the past few weeks, it’s been happening more. Last Sunday, I asked my daughter to bring me right home after lunch. Usually, we might go shopping or take our time, but I just felt like I should lay down.

Clinician: Did the rest help?

Patient: Honestly, it didn’t seem to help. My chest felt a little heavy too, so that’s when I decided to make an appointment with you.

Clinician: Ok, I’m glad you’re here so we can figure out what is causing your symptoms.

AF Screening and Diagnosis

Christian T. Ruff, MD, MPH: Hello and welcome to this program. I'm Christian Ruff, Director of General Cardiology at Brigham and Women's Hospital and Associate Professor of Medicine at Harvard Medical School in Boston, Massachusetts.

Margaret is a typical patient that we see in clinical practice with a medical history and new symptoms that are suggestive of the presence of atrial fibrillation (AF). Worldwide, AF is the most common sustained cardiac arrhythmia, and the incidents and prevalence are increasing globally. The lifetime risk of AF is approximately 1 in 3 individuals of European ancestry over the age of 55. Increasing age is an important risk factor for AF, but other comorbidities including hypertension, diabetes, heart failure, coronary artery disease, chronic kidney disease, obesity and obstructive sleep apnea are also important contributors.

Patients with AF face an increased risk of thromboembolic stroke, death, and other complications. The rate of cardioembolic stroke attributable to AF has tripled during the past few decades and is projected to continue rising in the coming decades with the aging of the population. Early detection of AF plays an important role in preventing embolic stroke, as well as slowing or stopping the progression of anatomical or electrical abnormalities that can lead to refractory disease. The increasing burden of AF and significant morbidity mortality associated with AF encourage screening for AF in clinical practice.

Screening for AF can include opportunistic screening or systematic screening in people above a certain age, 65 years and older, for example, or with characteristics indicating a high stroke risk. There are several screening tools available with various sensitivities and specificities. Importantly, when AF is detected by a screening tool, including mobile or wearable device, an ECG should be obtained to make a definitive diagnosis of AF and provide appropriate management.

For our patient, given Margaret's history and current complaints, a diagnostic workup for AF is indicated. This includes a 12-lead ECG to establish the diagnosis of AF, assess ventricular rate, and check for the presence of conduction defects, ischemia, or signs of structural heart disease. This is a class one recommendation. Other labs who obtain at this time include thyroid and kidney function tests, electrolytes, and complete blood count. Let's return to the patient to see how she's doing.

Case Study, Part 2

Clinician: Ok Marge, I’ve looked over the results of your ECG and you have AF. Have you heard of that before? It’s commonly called A FIB.

Patient: Yes, I have. It’s something with your heartbeat, right? My friend Betty had it a few years ago. Now that I think about it, she was tired and out of breath a lot too.

Clinician: Yes, atrial fibrillation, or “afib” is when you have an irregular heartbeat. Often your heart rate can be very fast, which can feel like palpitations and cause you to be tired or short of breath. Afib is very common. About one in three, maybe even one in two people will experience it at some point in their life. So, it’s not surprising that you know someone who has had it.

Patient: I hope that means we can make it go away?

Clinicians: Well, there are two main factors to consider with afib. The first part is we need to slow your heart rate and then try to get you back into a normal rhythm. We can get you started on some medication today and schedule you for a procedure called cardioversion in a few weeks.

Patient: Oh, wow a procedure. You said it’s common though, right?

Clinician: Yes, very common. The nurse will go over the details with you and answer any questions you might have about it, but basically, we give you a little bit of sedation and then provide a small electrical jolt through pads on your chest to revert you back to your normal heart rhythm. Once your heart rate is back in a normal rhythm that should help you feel much better physically.

Patient: Ok, the sooner I start feeling back to normal the better.

Clinician: The second part of managing afib, and the most important, is to prescribe you an anticoagulant or blood thinner to lower your risk of stroke.  We know that once you are diagnosed with afib, even if we get you back into a normal rhythm, you are 5 times more likely to experience a stroke. And strokes due to afib are some of the most severe strokes we see. Fortunately, taking an anticoagulant lowers your risk substantially, by about 80%.

Patient: Oh no! Really? That seems odd, isn’t a stroke in your brain? And afib is in your heart. So that doesn’t make sense to me.

Clinician: It does seem surprising to most people. But having afib can cause you to form blood clots in your heart, which can then travel to your brain. We know that the risk of forming clots due to afib increases as we get older, and if patients have hypertension, diabetes, and other medical conditions.

Patient: Ok.

Stroke Prevention and Antithrombotic Therapy

Dr Ruff: Strokes attributed to AF are not only severe, with a high incidence of substantial disability, but also have a considerable risk for recurrence. Thus, stroke prevention is a key component of the management of patients with AF. Selection of a stroke prevention strategy is based on the patient's risk for stroke, as well as risk for bleeding.

In patients with AF, except with moderate to severe mitral stenosis or mechanical heart valve, the CHA2DS2-VASc score is recommended to assess for stroke risk. The HAS-BLED score is a common tool used to assess bleeding risk. An appropriate stroke prevention strategy needs to balance the risk for stroke with the risk for bleeding. In both US as well as European guidelines, non-vitamin K oral anticoagulants (NOACs) are recommended over vitamin K antagonist (VKAs) for stroke prevention in patients with AF who are eligible for oral anticoagulation. This is a class one recommendation. That is in patients with a CHA2DS2-VASc score of two or greater in men or three and greater in women.

Support for the use of NOACs versus warfarin comes from four randomized clinical trials. These trials demonstrated that NOACs are non-inferior or superior to warfarin in preventing stroke or systemic embolism. However, in a meta-analysis of these trials, NOACs were associated with a significantly better safety profile, including a 52% reduction in intracranial hemorrhage and a 14% reduction in major bleeding risk, albeit at an increased risk for gastrointestinal (GI) bleeding.

Patients for whom a NOAC may not be appropriate include those at a low risk for stroke, and that's a CHA2DS2-VASc score of zero in men or one in women, or patients with AF and a moderate to severe mitral stenosis or mechanical heart valve. Now, warfarin is indicated in this population or patients that have any contraindication to NOAC therapy. Our patient, Margaret, has a moderate stroke risk. CHA2DS2-VASc score of 5 with a relatively low risk for bleeding, a HAS-BLED score of 2. Thus, a NOAC is the most appropriate thromboprophylaxis strategy for her.

There are no randomized control trials directly comparing one NOAC to another. Anticoagulant therapy should be individualized on the basis of a shared decision-making after discussion of the absolute risks and relative risks of both stroke and bleeding, as well as the patient's values and preferences. Prior to starting NOAC therapy the importance of adherence should be discussed and any potential barriers to adherence identified.

Furthermore, for clinicians, the importance of adequate NOAC dosing cannot be under-emphasized. NOAC dose should be adjusted based on patients' age, weight, renal function, and certain concomitant drug therapy. While off-label, reduced doses of NOACs can be common in routine clinical practice, this leads to reduced effectiveness without a safety benefit. Let's return to Margaret. She has started anticoagulant therapy and underwent electrical cardioversion.

Case Study, Part 3

Clinician: Hello again, Marge. I see you were cardioverted last week and your heart rate is back to a normal rhythm. Today it’s at 70 beats per minute. How did the procedure go and how are you feeling now?

Patient: I was a bit nervous, but it went really well and I’m feeling so much better, thankfully. 

Clinician: I’m glad to hear that. And you’re still taking your anticoagulant every day as prescribed?

Patient: I am, but I've had some bruising in the last two weeks. Since my heart rate is better now, do I really need to keep taking the blood thinner?

Clinician: Absolutely! As I mentioned previously, your risk of stroke from afib is lifelong and does not go away even when your heart rhythm is back to normal. So, the anticoagulant needs to be continued. The type of anticoagulant you’re taking is called a NOAC and these drugs are very effective. They lower your risk of stroke by about 80%.

Patient: Ok, but what can I do about the bruising?

Clinician: Some minor bleeding and bruising can be expected, but it is important to continue taking your anticoagulant. We know the risk of serious bleeding with NOACs is very low. I don’t want to scare you, but strokes caused by afib are very serious. About 20% are fatal, and half of people who do survive have permanent disability.

Patient: Oh. Ok, I don’t want to go through any of that.

Clinician: Let’s see if any of your medications might be contributing to your bleeding. I don’t see anything concerning in your chart and we’ve stopped your baby aspirin, correct?

Patient: Yes. I don’t take that anymore.

Clinician: Are there any new medications you have been taking?

Patient: The only thing is my pain medicine for my joints. I’ve been taking that a few times a day because my knees have been bothering me…it’s just ibuprofen.

Clinician: Hmm, do you know how many milligrams you have been taking?

Patient: It’s the stronger one from the pharmacy.

Clinician: Ok, the prescription strength is 800 mg, which is a high dose, and may be causing some bleeding. NOACs alone have a very low risk of bleeding especially compared to older blood thinners. But Ibuprofen which is a nonsteroidal anti-inflammatory drug (NSAID) can actually increase your risk of bleeding when you’re taking a NOAC by about 50%.

Patient: Oh dear! I didn’t realize! What can I do for the pain then? I need to take something!

Clinician: You don’t have to fully stop taking ibuprofen all together. I recommend you take the over-the-counter version and only take 400 mg at a time. Also only take it when you really need it. Now acetaminophen does not cause bleeding. So, you can even alternate taking acetaminophen and ibuprofen to help manage the pain. 

Patient: Ok, I will try alternating them. Thank you.

Clinician: Another important thing is to pay close attention not to miss a dose of your blood thinner. Do you use a pill reminder or anything to help you keep track of when you take your medications?

Patient: Yes, and my daughter helps me organize my meds each week.

Clinician: Ok that’s great because if you forget a dose of the blood thinner, you're totally unprotected from having a stroke until your next dose.

Patient: Ok. I’ll be sure to let my daughter know how important this new medicine is.

Clinician: Great. I’m happy to see things are going in the right direction. Let’s get you set up for another follow-up appointment and by reducing the ibuprofen dose your signs of bleeding should subside.

Safety and Medical Adherence

Dr Ruff: Bleeding is commonly cited as the main reason for stopping anticoagulant therapy or skipping doses. Both modifiable and non-modifiable factors dictate a patient's bleeding risk. Assessment of modifiable bleeding risk factors should be made at every patient contact. Formal bleeding risk assessment can help identify high risk patients who should be monitored on a more frequent basis. Very minor bleeding, what we call nuisance bleeding, is substantially more common than the most serious adverse bleeding events like GI bleeding in patients taking NOAC therapy.

Because nuisance bleeding was not systematically collected in most randomized clinical trials, it's really difficult to know the true incidents of nuisance bleeding in patients on any NOAC therapy. It is known, however, that patients have a greater risk for morbidity and mortality with early discontinuation of anticoagulant therapy. Thus, we really want to strongly encourage that our patients continue NOAC therapy with high adherence, despite the occurrence of infrequent but nuisance bleeding.

Furthermore, data from the ORBIT-AF registry demonstrated that the occurrence of very minor bleeding was not associated with an increased risk of major bleeding, or of stroke or systemic embolism as compared with patients in the prior six months versus those who hadn't had this very minor bleeding. These data suggest that episodes of nuisance bleeding shouldn't necessarily lead to changes in stroke prevention therapy. We can, however, provide some additional suggestions to Margaret regarding her potential risk for bleeding, like minimizing other medications that can increase bleeding potential, as well as being cautious about certain high-risk activities, being careful when she trims her hair or nails, or using a soft toothbrush for brushing her teeth.

In conclusion, the key take home messages are patients with AF are at a high risk of stroke. Early screening for and diagnosis of AF play an important role in preventing stroke, as well as other morbidity and mortality. NOACs are recommended over vitamin K antagonists for stroke prevention in patients that are eligible for oral anticoagulation and an individual's risk for stroke must be balanced against the risk of bleeding. Bleeding risks should be assessed at every clinical encounter, be it in person or over the phone.

I hope that you find the information and suggestions we discussed today useful to you in your clinical practice. Thank you for participating in this activity, and please continue on to answer the questions that follow and complete the evaluation.

This transcript has not been copyedited.

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