Managing Patients with Atrial Fibrillation

1
Managing Patients with Atrial Fibrillation

• Understanding AF and Introducing MULTAQTM, a New
  Antiarrhythmic Drug

2
Contents

• 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

3
I. Atrial Fibrillation Definition and Aetiology
4
Question
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
5
In 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)
6
AF 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
7
II. The Consequences of AF
8
Question
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
9
AF 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
10
AF 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
11
AF 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
12
AF 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
13
Question
How many patients are hospitalised for AF per
year in ltcountrygt? Please select one option only
A
x
B
y
C
z
14
AF 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

15
Studies 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

16
Increasing 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
17
III. Diagnosing AF Patients
18
Question
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
19
Diagnosing 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
20
IV. Current Treatment Strategies for AF
21
Question
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

22
Current 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
23
Anti-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.
24
Vaughan-Williams Classification

• AADs have distinct characteristics depending on
  which ion channels they block

Vaughan Williams EM. J Clin Pharmacol. 1984
24(4)129-47
25
A Range of Non-pharmacological AF Treatment
Options Exist
Ablate and pace
Catheter
AV node
Lip et al. Lancet 2007370604-18
26
Guidelines 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
27
Guidelines 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
28
Current 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
29
Currently 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
30
V. Atrial Fibrillation Key Points
31
Atrial 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

32
MULTAQ
Introducing

• A new anti-arrhythmic drug
• for the treatment of
• Atrial Fibrillation/Atrial Flutter

33
MULTAQ 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
34
MULTAQ

• has rhythm and rate control properties to help
  patients stay symptom free

35
MULTAQ 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
36
6 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
37
Dronedarone 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
38
MULTAQ 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
39
MULTAQ 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
40
Dronedarone 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
41
MULTAQ

• is the only AAD to have demonstrated a CV
  morbidity and mortality benefit in AF

42
MULTAQ 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
43
MULTAQ 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
44
MULTAQ 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
45
MULTAQ 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
46
Significant 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.
47
MULTAQ 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
48
Dronedarone 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"
49
MULTAQ

• has a favourable safety and tolerability profile,
  and a convenient dosing regimen

50
In 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
51
MULTAQ Demonstrated a Favourable Tolerability
Profile in Over 6,700 patients1
52

• Sanofi-aventis data on file
• MULTAQ US PI

52
MULTAQ has a Fixed Dosing Regimen
400 mg bid with food No loading dose No
titration
53
MULTAQ SmPC
53
MULTAQ

• in your AF patients

54
MULTAQ 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
55
MULTAQ 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
56
MULTAQ 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

57
Prescribing MULTAQ with Other TreatmentsDrug
Drug Interactions
58
MULTAQ SmPC
58
Prescribing MULTAQ with Other TreatmentsDrug
Drug Interactions
For full details on drug-drug interactions,
please see MULTAQ SmPC
59
MULTAQ SmPC
59
MULTAQ 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
60
Clinical cases
61
Proposed 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
62
Clinical 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
63
Clinical 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
64
Clinical 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
65
Clinical 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
66
Clinical Case 1 Martin
Recommended action

• Even if asymptomatic, refer Martin to a
  specialist to consider prescribing MULTAQ as an
  AAD option

67
67
Clinical 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
68
Clinical 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
69
Clinical 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
70
Clinical 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
71
Clinical Case 2 Mark
Recommended action

• Refer Mark to a specialist to consider switching
  current AAD therapy for MULTAQ

72
72
Clinical 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
73
Clinical 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
74
Clinical 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
75
Clinical 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
76
Clinical Case 3 Monica
Recommended action

• Continue MULTAQ prescription, ensuring each dose
  is taken with food

77
77
Clinical 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
78
Clinical 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
79
Clinical 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
80
Clinical 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
81
Clinical Case 4 Alex
Recommended action

• Continue MULTAQ prescription
• Observe for spontaneous cardioversion
• Cardiovert if want rhythm control
• Adjust background beta blocker dose

82
82
Clinical 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
83
AF 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
84
Clinical 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