Title: Managing Patients with Atrial Fibrillation
1Managing Patients with Atrial Fibrillation
- Understanding AF and Introducing MULTAQTM, a New
Antiarrhythmic Drug
2Contents
- Understanding Atrial Fibrillation (AF)
- AF Definition and Aetiology
- The Growing Burden of AF
- The Consequences of AF
- Diagnosing AF Patients
- Current Treatment Strategies for AF
- AF Key Points
- Introducing MULTAQ
- A New Antiarrhythmic drug
- Rhythm and Rate Control
- CV Morbidity and Mortality
- Safety and Tolerability
- MULTAQ Key Points
- MULTAQ Clinical Cases
3I. Atrial Fibrillation Definition and Aetiology
4Question
Which of the following is true about Atrial
Fibrillation (AF)? You may select multiple options
A
AF is an abnormal cardiac rhythm
B
AF is caused by a non-functioning sinus node
C
In AF, the atria can contract at up to 600 beats
per minute
5In AF, Control of the Heart Rhythm is Taken Away
from the Sinus Node
Sinus Rhythm
Atrial Fibrillation
Sinus node
Abnormal electrical pathways
Normal electrical pathways
- Multiple co-existing wavelets cause rapid and
irregular atrial activity (400-600 bpm)
Veenhuyzen GD et al. CMAJ 2004171(7)
6AF is Classified by Episode Duration and the
Ability to Return to Sinus Rhythm
1st Detected
Recurrent if 2 episodes
Paroxysmal(self terminating - usually within 7
days)
Persistent(not self terminating)
Permanent (Refractory to cardioversion and/or
accepted)
ACC/AHA/ESC 2006 guidelines J Am Coll Cardiol
200648854-906
7II. The Consequences of AF
8Question
Symptoms of AF may include You may select
multiple options
A
Heart palpitations
B
Shortness of breath
C
Fever
D
Back pain
E
Chest pain
9AF May Present with a Wide Range of Symptoms
- However, symptoms may be absent
- Asymptomatic episodes
- Older patients with permanent AF
ACC/AHA/ESC 2006 guidelines J Am Coll Cardiol
200648854-906
10AF Increases the Risk of Mortality
- AF approximately doubles the risk of mortality1
- AF increases the risk of sudden cardiac death by
1.312
0.25
80
Age 55-74 years
70
0.20
60
0.15
50
X2
Percent of Subjects Dead in Follow-up
Sudden cardiovascular mortality probability
40
X1.31
0.10
30
20
0.05
10
0
0.00
0
1
2
3
4
5
6
7
8
9
10
2
3
0
1
Years of Follow-up
Time from MI in years
Men AF (n159)
Women AF (n133)
Without AF/AFL
Men no AF (n318)
Women no AF (n266)
1. Benjamin EJ et al. Circulation
199898946-952 2. Pedersen OD et al. EHJ
200627290-5
11AF Increases the Risk of Morbidity
- AF patients have a near 5-fold increased risk of
stroke1
- AF patients have a 3.4 times increased risk of
heart failure2
Affected portion of the brain
Embolus blocks blood flow to part of the brain
Embolus (clot)
Thrombus (clot)
- Heart failure predisposes to AF and AF
exacerbates heart failure3
1. Wolf et al. Stroke. 199122983-988 2. Stewart
et al. Am J Med. 2002113359 364 3. Maisel WH
et al. Am J Cardiol 200391(suppl)2D-8D
12AF Worsens the Prognosis of Patients with
Comorbidities
1. Adapted from Wachtell K et al. J Am Coll
Cardiol 200545712-719 2. Adapted from Wang et
al. Circulation 20031072920-2925 3. Adapted
from Pizzetti F et al. Heart 200186527-532
13Question
How many patients are hospitalised for AF per
year in ltcountrygt? Please select one option only
A
x
B
y
C
z
14AF Leads to Hospitalisation
- Hospitalisation rates for AF have increased
dramatically in recent years2-4
- AF patients are at a 2-3 times increased risk of
hospitalisation1
Hospitalisation rate X 2 to 3 (US - 1985 to
1999)2
Risk of hospitalisation X 2-31
- Stewart S et al. Am J Med 2002113359-364
- Stewart S et al. Eur Heart J 2001 693701
- Friberg J et al. Epidemiology 200314 666672
- Wattigney WA Circulation 2003108711-716
15Studies Reveal High Hospitalisation Rates Among
AF Patients
50
follow-up 1 year
mean follow-up 21 months
40
36.9
36.9
30
hospitalised for CV reasons
follow-up 1 year
20
17.0
10
0
Euro Heart Survey2,3
ATHENA (placebo arm)1
RecordAF Registry4
- First hospitalisation due to cardiovascular
event - Hohnloser SH et al. N Engl J Med 2009360668-78
- Nieuwlaat R et al. European Heart Journal
20082911811189 - MULTAQ European Public Assessment Report
- Camm J. RecordAF Registry. Scientific sessions
AHA 2009
16Increasing Rates of Hospitalisation are
Associated with Poorer Quality of Life
Hospitalisations
2.6
3
ER visits
2.1
Mean number in one year
2
1.7
1.0
0.8
0.9
1
0.4
0.3
0.3
0.1
1
0
2
3
4
Severity of AF (SAF) scale (increasing value
corresponds to poorer QoL)
- Mean number of specialist visits and the
proportion of patients who had a cardioversion
also increased with decreasing QoL
EREmergency Room Dorian P et al. Circ Arrhythmia
Electrophysiol 20092218-224
17III. Diagnosing AF Patients
18Question
What is the conclusive electrical sign of AF on
an ECG? Please select only one option
A
C
The absence of P waves
The absence of R waves
B
D
The absence of T waves
The absence of QRS waves
19Diagnosing AF
ECG - Sinus Rhythm
R
R
T
P
Q
P wave
S
ECG - Atrial Fibrillation
No clear P wave
Van Weert HC. BMJ 2007335355-6
20IV. Current Treatment Strategies for AF
21Question
Which of the following best describes the two
main current objectives in the management of
patients with AF? Please select only one option
A
- Correction of the rhythm disturbance
- Reduction of heart rate
B
- Stroke Prevention in elderly patients
- Reduction of heart rate
C
- Stroke Prevention
- Correction of the rhythm disturbance
D
- Stroke Prevention
- Correction of the rhythm disturbance and/or rate
control depending on patient symptoms
22Current Treatment Patterns Focus Primarily on
Stroke Prevention and Symptom Management
Proven impact on morbidity/mortality
1
Prevent thromboembolic complications
Relieve AF symptoms
2
Short term treatment
Decrease heart rate (as needed)
Rhythm control
Rate control
NO proven impact on morbidity/mortality
Long term strategy
If remains symptomatic
After 3 to 5 AF recurrences
Common concern about rate and rhythm safety
Adapted from Fuster V, et al. Eur Heart J
2006271979-2030
23Anti-thrombotic Therapy is Essential forReducing
Risk of Stroke
- Current clinical practice recommends that
anticoagulation should be continued for life in
patients at high risk of thrombo-embolism or with
risk factors for atrial fibrillation recurrence1 - The CHADS2 (Cardiac Failure, Hypertension, Age,
Diabetes, Stroke Doubled) is a points based
system for predicting risk of stroke in AF, based
on key risk factors1,2 - Prior stroke or TIA 2 points
- Age gt75y 1 point
- Hypertension 1 point
- Diabetes mellitus 1 point
- Heart failure 1 point
TIA transient ischemic attack 1. ACC/AHA/ESC
2006 guidelines J Am Coll Cardiol
200648854-906 2. Gage BF et al. JAMA
2001285286470.
24Vaughan-Williams Classification
- AADs have distinct characteristics depending on
which ion channels they block
Vaughan Williams EM. J Clin Pharmacol. 1984
24(4)129-47
25A Range of Non-pharmacological AF Treatment
Options Exist
Ablate and pace
Catheter
AV node
Lip et al. Lancet 2007370604-18
26Guidelines Recommend Comprehensive Management of
AF
Improve outcomes of AF "disease"
Prevent AF recurrence
Slow ventricular response
Impactassociated risks
CV effects
Rhythm control
Rate control
Treat AF "Arrhythmia"
The main selected strategy could be either
rhythm or rate control, or their combination The
other components optimise the treatment effect
and contribute to improve outcomes
ACC/AHA/ESC 2006 guidelines J Am Coll Cardiol
200648854-906
27Guidelines for AAD use in Maintaining Sinus Rhythm
Maintenance of Sinus Rhythm
Coronary arterydisease
No (or minimal)heart disease
Hypertension
Heart failure
Flecainide Propafenone Sotalol
Amiodarone Dofetilide
Dofetilide Sotalol
Substantial LVH
Catheterablation
Catheterablation
AmiodaroneDofetilide
Catheterablation
Amiodarone
No
Yes
Flecainide Propafenone Sotalol
Amiodarone
Guidelines are due to be updated in 2010
Catheterablation
AmiodaroneDofetilide
Catheterablation
ACC/AHA/ESC 2006 guidelines J Am Coll Cardiol
200648854-906
28Current Treatment Paradigm Focuses on Rhythm or
Rate Control Strategies
- Several clinical studies have failed to show any
significant difference between rhythm and rate
control in terms of CV morbidity and mortality14 - Rhythm control
- Can achieve sinus rhythm, but may be limited by
adverse events5 - Rate control
- Controls ventricular rate only and leaves
patients in AF5,6 - Adequate rate control is not easily nor
consistently achieved7 - Doses of ß-blockers and heart rate-lowering
calcium channel blockers to achieve adequate rate
control are associated with side effects
(fatigue, impaired exercise tolerance, impotence,
etc.)7 - Cheaper and more convenient than rhythm control6
1. Roy D, et al. N Engl J Med 20083582667-77 2.
Van Gelder IC, et al. N Engl J Med
20023471834-40 3. Wyse DG, et al. N Engl J Med
20023471825-33 4. Corley SD, et al. Circulation
20041091509-13 5. Nattel S, Opie LH, Lancet
2006367262-72 6 Camm JA, Saveleiva I. J
Interv Card Electrophysiol 2008237-14 7. Lip
GY, Tse HF, Lancet 2007370604-18
29Currently Available AADs can have Limited
Efficacy and Serious Safety Issues
- No previously available AAD had been shown to
reduce CV outcomes (unplanned CV
hospitalisations, CV mortality) - Limited efficacy
- Most AADs have been shown to be 5065 effective
in maintaining normal sinus rhythm over 6 to
12-months1 - Some may be associated with serious adverse
events2 - Proarrhythmias (e.g. torsades de pointes)
- Congestive heart failure
- Organ toxicity
- Neurotoxicity
- Pulmonary toxicity
- Hepatic toxicity
- Optic neuropathy
- Thyroid abnormalities
1. Naccarelli GV et al. Am J Cardiol
200391(suppl)15D-26D 2. Camm AJ. Int J Cardiol
2008127299-306
30V. Atrial Fibrillation Key Points
31Atrial Fibrillation Key Points
- AF significantly increases a patients risk of CV
morbidity and mortality - AF is the leading cause of hospitalisations for
arrhythmia - Studies reveal high rates of hospitalisation for
AF of around 40 of patients - Increasing rates of hospitalisation are
associated with poorer quality of life - Currently available anti-arrhythmic therapies
have no proven efficacy on CV outcomes and may be
associated with serious adverse events - In the past, management of patients with AF only
focused on 2 key objectives - prevention of
thromboembolism, and symptom control - Today, comprehensive management of AF should
address its multiple impacts including reduction
in CV events and hospitalisation
32MULTAQ
Introducing
- A new anti-arrhythmic drug
- for the treatment of
- Atrial Fibrillation/Atrial Flutter
33MULTAQ has a Unique Profile for an AAD
- Possesses rhythm control, rate control,
vasodilatory, anti-adrenergic and blood pressure
lowering properties1 - Reduces AF recurrence and lowers ventricular rate
to help patients stay symptom free2,3 - Is the only AAD to have demonstrated a CV
morbidity and mortality benefit in AF4 - Is associated with a low risk of extra-cardiac
toxicities and proarrhythmias1 - Has a favourable tolerability profile and a
convenient fixed dosing regimen1
- MULTAQ SmPC
- Singh BN et al. N Engl J Med 200735798799
- Davy et al. Am Heart J 2008156527.e1-527.e9
- Hohnloser SH et al. J Cardiovasc Electrophysiol
20081969-7
34
34MULTAQ
- has rhythm and rate control properties to help
patients stay symptom free
35MULTAQ Extends Time in Sinus Rhythm for both
Symptomatic and Asymptomatic Patients
Patients in both arms received standard therapy
, which may have included rate control agents
(beta-blockers, and/or calcium channel
antagonists and/or digoxin) and/or
anti-thrombotic therapy (Vitamin K antagonists
and/or aspirin and other antiplatelet therapy)
and/or other cardiovascular agents such as
ACEIs/ARBs and statins.
Singh BN et al. N Engl J Med 200735798799
36
366 out of 10 Patients on MULTAQ were Free of
Symptomatic AF Recurrence at 1 Year
plt0.001
37
Singh BN et al. N Engl J Med 200735798799
37Dronedarone Demonstrates Consistent Rhythm
Control Efficacy Across Studies and AF Populations
- Touboul P, et al. Eur Heart J. 2003241481-7
- DIONYSOS JCE in press
- Singh BN, et al. N Engl J Med. 2007357987-99
- Hohnloser SH et al. N Engl J Med 2009360668-78
Median duration Mean duration
38
38MULTAQ Reduces Ventricular Rate Across the
Spectrum of AF Patients
2
1
- Singh BN et al. N Engl J Med 200735798799
- Davy et al. Am Heart J 2008156527.e1-527.e9
39
39MULTAQ Provides Additional Rate-lowering Benefits
on Top of Standard Rate Control Therapy in
Permanent AF Patients
40
Davy et al. Am Heart J 2008156527.e1-527.e9
40Dronedarone Demonstrates Consistent Rate Control
Efficacy Across Studies and AF Populations on Top
of Standard Rate Control Therapy
- Touboul P et al. Eur Heart J. 2003241481-7
- Davy et al. Am Heart J, Vol 156 (3) 527.
e1-527e9 - Singh BN et al. N Engl J Med. 2007357987-99
- 4. Page R et al. AHA Scientific Sessions 2008
41
Mean duration
41MULTAQ
- is the only AAD to have demonstrated a CV
morbidity and mortality benefit in AF
42MULTAQ Significantly Decreased Risk of CV
Hospitalisation or All-Cause Death by 24
The number of patients needed to treat to save
one cardiovascular hospitalisation or death from
any cause is 13
Kaplan-Meier cumulative incidence of primary
endpoint
- Standard therapy may have included rate control
agents (beta-blockers, and/or calcium channel
antagonists and/or digoxin) and/or
anti-thrombotic therapy (Vitamin K antagonists
and/or aspirin and other antiplatelet therapy)
and/or other cardiovascular agents such as
ACEIs/ARBs and statins. Mean follow-up 21 5
months. - Hohnloser SH et al. N Engl J Med 2009360668-78
43
43MULTAQ Significantly Decreased Risk of Arrhythmic
Death by 45 and CV death by 29
44
Mean follow-up 21 5 months. Hohnloser SH et al.
N Engl J Med 2009360668-78
44MULTAQ Significantly Decreased the Risk of
Cardiovascular Hospitalisation by 26
Kaplan-Meier cumulative incidence of secondary
endpoint
45
Mean follow-up 21 5 months. Hohnloser SH et al.
N Engl J Med 2009360668-78
45MULTAQ Significantly Decreased Total CV
Hospitalisation Days by 35
- MULTAQ led to a decrease of 1.02 CV
hospitalisation days/patient/year - For every 1000 patients treated with MULTAQ for
one year, the healthcare system would save 1020
CV hospitalisation days
On treatment analysis. Torp-Pedersen, et al. AHA
Scientific Sessions 2008 Data on file.
46
46Significant Decrease in CV Hospitalisation with
MULTAQ Comprises of a Decrease in AF and Non-AF
Hospitalisations
Hohnloser SH, et al. N Engl J Med 2009360668-78.
47MULTAQ Significantly Decreased the Risk of Stroke
by 34
Cumulative Incidence ()
Months
6
12
18
24
30
0
- Patients in both arms were receiving appropriate
anti-thrombotic therapy, e.g. Vit. K antagonists
and /or aspirin and other antiplatelet therapy
Mean follow-up 21 5 months. Connolly SJ et al.
Circulation 2009120(13)1174-80
48Dronedarone Offers Patients not Only a New
Treatment for AF But a New Treatment Approach
Management of AF "disease"
ATHENA
EURIDIS / ADONIS
ERATO
Prevent AF recurrence
Provide rate control
Impactassociated risks
Treat AF "Arrhythmia"
49MULTAQ
- has a favourable safety and tolerability profile,
and a convenient dosing regimen
50In a Clinical Programme of Over 6,700 AF
Patients, MULTAQ Demonstrated a Favourable Safety
Profile1
Low risk of extra-cardiac toxicities2 Thyroid,
pulmonary, dermatologic
Low risk of pro-arrhythmias2 lt 0.1 patients
No clinically relevant interaction with OACs2
No liver, thyroid or lung monitoring2
Can be Initiated and administrated in an
outpatient setting2
Can be used in patients taking warfarin
- OACOral anticoagulant
- Sanofi-aventis data on file
- MULTAQ SmPC
51
51MULTAQ Demonstrated a Favourable Tolerability
Profile in Over 6,700 patients1
52
- Sanofi-aventis data on file
- MULTAQ US PI
52MULTAQ has a Fixed Dosing Regimen
400 mg bid with food No loading dose No
titration
53
MULTAQ SmPC
53MULTAQ
54MULTAQ is indicated
- in adult clinically stable patients
- with a history of, or current non-permanent
atrial fibrillation (AF) - to prevent recurrence of AF or to lower
ventricular rate
55
MULTAQ SmPC
55MULTAQ Special Warnings
- Because of the unexplained results of ANDROMEDA
study, the use of MULTAQ in unstable patients
with NYHA class III and IV heart failure is
contraindicated - Because of limited experience in stable patients
with recent (1 to 3 months) NYHA class III heart
failure or with Left Ventricular Ejection
Fraction (LVEF) lt35, the use of MULTAQ is not
recommended
MULTAQ SmPC For more details on
contraindications, please see the SmPC
56
56MULTAQ Inhibits the Secretion of Creatinine in
the Kidneys, but is not Indicative of Renal
Toxicity1,2
- Plasma creatinine values should be measured 7
days after initiation of MULTAQ - An increase in plasma creatinine has been
observed with MULTAQ 400 mg twice daily in
healthy subjects and in patients, which occurs
early after treatment initiation and reaches a
plateau after 7 days - If an increase in creatininemia is observed, this
value should be used as the new reference
baseline taking into account that this may be
expected with MULTAQ - An increase in creatininemia should not
necessarily lead to the discontinuation of
treatment with ACE-inhibitors or Angiotensin II
Receptors Antagonists
57
- MULTAQ SmPC
- Tschuppert et al. Br J Clin Pharmacol
200764(4)785-91
57Prescribing MULTAQ with Other TreatmentsDrug
Drug Interactions
58
MULTAQ SmPC
58Prescribing MULTAQ with Other TreatmentsDrug
Drug Interactions
For full details on drug-drug interactions,
please see MULTAQ SmPC
59
MULTAQ SmPC
59MULTAQ Key Points
- MULTAQ exhibits both rhythm and rate control
efficacy and has been proven to significantly
prolong time to AF recurrence and decrease
ventricular rate - MULTAQ is the only anti-arrhythmic drug ever
proven to significantly reduce CV hospitalisation
or all-cause mortality, in ATHENA, the largest
AAD trial in atrial fibrillation - MULTAQ demonstrates a low risk of pro-arrhythmias
and extra-cardiac toxicity, with favourable
tolerability - MULTAQ is easy-to-use because of its fixed-dosing
regimen, outpatient initiation and minimal
monitoring requirements
60
60Clinical cases
61Proposed Treatment Algorithm for Dronedarone in AF
Maintenance of Sinus Rhythm
No (or minimal)heart disease
Coronary arterydisease
Hypertension
Heart failure
NYHA Class III/IV
NYHA Class I/II
Dronedarone Dofetilide Sotalol
Dronedarone Flecainide Propafenone Sotalol
Substantial LVH
Amiodarone Dofetilide
Catheterablation
No
Yes
Amiodarone
Catheterablation
AmiodaroneDofetilide
Dronedarone Flecainide Propafenone Sotalol
Dronedarone Amiodarone Dofetilide
Dronedarone Amiodarone
Catheterablation
Catheterablation
Catheterablation
AmiodaroneDofetilide
Adapted from Prystowsky EN. Nat Rev Cardiol.
20107(1)5-6
62Clinical Cases Summary
Martin
An AF patient, currently managed through rate
control
Mark
GP
An AF patient , currently managed with amiodarone
Monica
Follow-up of a patient on MULTAQ experiencing GI
side effects
Alex
Follow-up of a patient on MULTAQ with mild
symptomatic AF recurrence
63Clinical Case 1 Martin
- 65 years old
- Clinical findings and history
- Paroxysmal AF
- Last symptoms 4-5 months ago
- Resting HR 80 bpm and irregular
- Blood pressure 130/85 mmHg
- Type 2 diabetes for 10 years, HbA1c 7.2
- CAD (coronary artery disease)
64
64Clinical Case 1 Martin
- Current medications
- ACE Inhibitor (Angiotensin Converting Enzyme
Inhibitor) - Beta-blocker
- Insulin
- Warfarin
- Martin is seeing you for a check-up
How should Martin be managed?
65
65Clinical Case 1 Martin
How should Martin be managed?
- Continue current treatments
- Continue current treatments and add additional
rate control therapy e.g. calcium channel blocker - Refer to a Specialist to consider prescribing AAD
therapy
66
66Clinical Case 1 Martin
Recommended action
- Even if asymptomatic, refer Martin to a
specialist to consider prescribing MULTAQ as an
AAD option
67
67Clinical Case 1 Martin
Why refer to add MULTAQ?
- Savelieva I et al. Pacing Clin Electrophysiol
200023145-148 - Hohnloser SH et al. N Engl J Med 2009360668-78
- Singh BN, et al. N Engl J Med. 2007357987-99
- Davy et al. Am Heart J, Vol 156 (3) 527.
e1-527e9 - MULTAQ SmPC
68
68Clinical Case 2 Mark
- 75 years old
- Clinical findings and history
- Persistent AF for 9 months
- No AF symptoms at present
- Blood pressure 135/80 mmHg
- LDL-c 110 mg/dL
- Previous MI
- LVEF 50
69
69Clinical Case 2 Mark
- Current medications
- Fixed dose combination of ARB/HCTZ (angiotensin
receptor blocker/ hydrochlorothiazide) - Beta-blocker
- Statin
- Warfarin
- 6 months ago, recurrences on sotalol, patient
switched to amiodarone 200mg once daily - Mark is seeing you for a check-up
How should Mark be managed?
70
70Clinical Case 2 Mark
How should Mark be managed?
- Continue current treatments
- Discontinue amiodarone while continuing other
therapies - Refer to a Specialist to consider switching AAD
therapy
71
71Clinical Case 2 Mark
Recommended action
- Refer Mark to a specialist to consider switching
current AAD therapy for MULTAQ
72
72Clinical Case 2 Mark
Why refer to prescribe MULTAQ?
- Hohnloser SH et al. N Engl J Med 2009360668-78
- Singh BN, et al. N Engl J Med. 2007357987-99
- Davy et al. Am Heart J, Vol 156 (3) 527.
e1-527e9 - MULTAQ SmPC
- DIONYSOS JCE in press
73
73Clinical Case 3 Monica
- 70 years old
- Clinical findings and history
- Persistent AF
- No recurrence for 1 year
- Resting HR 90 bpm
- Blood pressure 130/90 mmHg
- Stable CHF NYHA Class 1
- TIA (Transient Ischemic Attack) 3 years ago
74
74Clinical Case 3 Monica
- Current medications
- Beta-blocker
- Warfarin
- ACE inhibitor and HCTZ (Angiotensin Converting
Enzyme Inhibitor / hydrochlorothiazide) - MULTAQ was prescribed one month ago
- Monica is feeling better on MULTAQ but reports
mild GI symptoms
How should Monica be managed?
75
75Clinical Case 3 Monica
How should Monica be managed?
- Continue current treatment
- Discontinue MULTAQ while continuing other
therapies - Refer to a Specialist to decide how to proceed
76
76Clinical Case 3 Monica
Recommended action
- Continue MULTAQ prescription, ensuring each dose
is taken with food
77
77Clinical Case 3 Monica
Why continue MULTAQ?
- MULTAQ SmPC
- Singh BN, et al. N Engl J Med. 2007357987-99
- Davy et al. Am Heart J, Vol 156 (3) 527.
e1-527e9 - Hohnloser SH et al. N Engl J Med 2009360668-78
- Connolly SJ et al. Circulation 2009120(13)1174-8
0
78
78Clinical Case 4 Alex
- 50 years old
- Clinical findings and history
- Persistent symptomatic AF
- Resting HR 85 bpm
- Blood pressure 142/92 mmHg
- Stable CHF NYHA Class II
- TIA (Transient Ischemic Attack) 1 year ago
79
79Clinical Case 4 Alex
- Current medications
- Beta-blocker
- Warfarin
- ACE inhibitor and HCTZ (Angiotensin Converting
Enzyme Inhibitor / hydrochlorothiazide) - MULTAQ
- Alex is experiencing mild symptomatic AF
recurrences on MULTAQ
How should Alex be managed?
80
80Clinical Case 4 Alex
How should Alex be managed?
- Continue current treatments, adjusting rate
control therapy if necessary - Discontinue MULTAQ and adjust rate control
therapy if necessary - Refer to a Specialist to decide how to proceed
81
81Clinical Case 4 Alex
Recommended action
- Continue MULTAQ prescription
- Observe for spontaneous cardioversion
- Cardiovert if want rhythm control
- Adjust background beta blocker dose
82
82Clinical Case 4 Alex
Why continue MULTAQ?
- Hohnloser SH et al. N Engl J Med 2009360668-78
- Connolly SJ et al. Circulation 2009120(13)1174-8
0 - MULTAQ SmPC
83
83AF Recurrence is Not Necessarily a Sign of
Treatment Failure
- In ATHENA, patients were in and out of AF
throughout the study duration - Based on the landmark ATHENA results, effective
AF management should now aim for a reduction in
CV risk and not solely a reduction in AF
recurrence
Sinus Rhythm
Asymptomatic AF episode
Symptomatic AF episode
CV outcomes(e.g. CV hospitalisation)
84
Hohnloser SH et al. N Engl J Med
2009360668-78 Page R et al. AHA Scientific
Sessions 2008
84Clinical Cases Summary
Martin
An AF patient, currently managed through rate
control
Refer to Specialist to consider MULTAQ initiation
Mark
GP
An AF patient, currently managed with amiodarone
Monica
Continue MULTAQ GI side effects usually transient
Follow-up of a patient on MULTAQ experiencing GI
side effects
Alex
Continue MULTAQ AF recurrence not necessarily a
sign of treatment failure
Follow-up of a patient on MULTAQ with mild
symptomatic AF recurrence