new updates about AF In the AMADEUS trial(4576 patients), Idraparinux was non inferior to warfarin but more risk of bleeding 19 % vs. 11%

1. Atrial Fibrillation
New update
June 2009
Dr Ihab Suliman
MBBS,ECFMG(USA),MRCP(UK),
DCBNC(USA)

2. Outline
• Introduction
• Importance
• Demographics
• Rate or Rhythm
• Anticoagulation
• Conclusion

3. AF
• Is the the most common sustained
arrhythmia.
• Above the age of 40, the life time risk of
developing AF is 25%.

4. Demographics
• 3 millions cases of AF in USA, 4.5 millions in
Europe.
• 83% of AF patients are above 65 years of age.

5. Associated Co-morbid issues with AF
• Hypertension 37%.
• CHF 23%.
• CAD 18%.
• Diabetes Mellitus 15%.

6. Importance
• Patients with AF even on optimum medical
therapy, have higher mortality than those with
Normal Sinus .
• Risk of stroke in non-valvular AF is 5 times
than those without, in case of valvular AF
riskis even much higher 18-23 times.

7. AF & Stroke
• AF is responsible for 15 % of all strokes.
• AF is the most important cause of stroke in
women above the age of 75 years.

8. AF & risk of stroke (CHADS2)
Risk of stroke(up to 20 fold) varies
depending on the clinical picture
Score(points) Prevalence(%)
Prior stroke or TIA 2 10
Age > 75 years 1 28
Hypertension 1 65
Diabetes Mellitus 1 18
Heart Failure 1 32

9. CHADS score , risk of stroke
Score ( points) Stroke Rate % per year VKAs vs. no VKAs crude
ratio( 95% relative risk)
0 0.5-2.2 0.50 (0.20-1.28)
1 2.0-4.5 0.47(0.30-0.73)
2 0.51(0.35-0.75)
3 0.42(0.28-0.62)
4 6-12 0.30(0.20-0.75)
5 0.67(0.28-1.60)

10. Rate or Rhythm
• AFFIRM trial showed no mortality difference.
• AF-CHF , showed even in heart failure, no
difference in mortality between the two
strategies.

11. Anticoagulation
• VKAs
• Antiplatelets.
• Thrombin inhibitor
• Factor Xa Inhibitor

12. Ximelagatran (Exanta)
First ever oral thrombin inhibitor
• Now out of clinical use due to liver toxicity
10%.
• Studied in Phase III trials like SPORTIF III(3407
patients ) SPORTIF V (3922 patients) vs.
warfarin.
• Rate of stroke was similar 1.6 % per annum,
marginally less bleeding with Ximelagatran

13. Idraparinux
Long acting Xa Inhibitor (once a WK)
• In the AMADEUS trial(4576 patients),
Idraparinux was non inferior to warfarin but
more risk of bleeding 19 % vs. 11%