Dr. (Prof) Mohan Nair MBBS, MD, DM

1) MAY -2015 to present: Co-ordinator & Head-Department of Cardiology, Holy Family Hospital, Okhla Road, New Delhi-110025.

2) 01-APRIL -2013 to MAY 2015: Chairman & Head-Department of Cardiology, Saket City Hospital, Saket, New Delhi 110017. Saket City Hospital (A Unit of Gujarmal

Modi Hospital & Research Centre for Medical Sciences) is a new world class hospital located at Saket, in the heart of New Delhi, as a healthcare centre, it is

driven by the credo of 'YOU FIRST.

3) 01-09-2007 to 31-03-2013: Director, Electrophysiology and Arrhythmia Services and Chief of Cardiology at Max Super Speciality Hospital, Patparganj, New Delhi,

Max Healthcare India.

4) Life-Time Professor of Cardiology, Punjab Institute of Cardiology, University of Lahore, Punjab

4) Program Chair, MMSc (Cardiology), Texila American University.

5) Honorary- Fellow, Ceylon College of Physicians

6) Currently: President, Indian Heart Rhythm Society

7) Asia Pacific Heart Rhythm Society

8) Cardiological Society of India

9) Indian College of Cardiology

10) Indian society of Electrocardiography

11) Secretary, Education Committee, Asian Pacific Society of Cardiology- 1991- 1995.

12) Invited Guest Faculty,- International EP and Pacing Conference, ”Cardiostim” Nice- Since 2000

13) Invited Speaker and Faculty, World Congress of Cardiology, Hong Kong- 2004

14) Guest Faculty, I Asian pacific Symposium on Atrial Fibrillation- Seoul, 2005

15) Member, Scientific Advisory Board, 2nd Asian pacific Symposium on Atrial Fibrillation, Japan- 2006

16) Manuscript Reviewer- American Journal of Cardiology, Indian Heart Journal.

17) Organising Secretary, 4th Asian Pacific Symposium on Cardiac Rehabilitation, New Delhi- 1994

18) Editorial Secretary, Indian Heart Journal- 1991-1992.

COORDINATOR & HEAD-DEPARTMENT OF CARDIOLOGY

HOLY FAMILY HOSPITAL

Stroke Prevention in Atrial Fibrillation :

Changing Landscape

Mohan Nair

Chief of Cardiology

Holy Family Hospital, New Delhi, India

Afib. Associated Stroke Has Greatly Increased Morbidity and Mortality

ISCHAEMIC STROKE is CATASTROPHIC*1-6

1. Savelieva I, et al. Ann Med. 2007;39:371-391. 2. Carlson M. http://cme.medscape.com. Accessed June 20, 2011. 3. Lin H-J, et al. Stroke.1996; 27:1760-1764. 4. Marini C, et al. Stroke. 2005;36:1115-1119. 5. Jorgensen HS, et al. Stroke.1996;27:1765-1769. 6. Kelly-

Hayes M, et al. J Stroke Cerebrovascular Dis. 2003;12:119-126.

Poorer outcomes

in survivors

Increased risk of

recurrent stroke

Stroke survivors

face persistent disability

Increased risk of death persists for 8

years

AF stroke

Poorer functional

performance in survivors

CARDIOEMBOLIC/AF-related STROKE

1) 30-Day MORTALITY – 25%3 2) 1 YEAR MORTALITY - ~50%4

300 Million Over the Age of 40

75 Million at Indians Have a Lifetime Risk of Atrial

Fibrillation

3.75 Million Lifetime Risk for Stroke!

IHRS Atrial Fibrillation Registry

• A national Atrial Fibrillation Registry was conducted under the aegis of the Indian Heart Rhythm Society to capture epidemiological data pertaining to

• prevalence and type of AF at the time of first diagnosis

• current followed treatment practices

• 1 year follow up visit data

Methods

• Enrolment from July 2011-August 2012, recruitment from 24 sites all over India

• Total number of patients enrolled:1532

• 1 year follow up available in 1375 (89.7%)

58

.16

%

47

.84

%

31

.03

%

18

.69

%

16

.05

%

12

.07

%

10

.45

%

9.1

7%

8.5

6%

8.1

6%

7.6

2%

7.5

5%

6.5

4%

5.5

3%

5.2

6%

4.4

5%

4.1

1%

3.9

1%

3.1

7%

1.8

8%

1.8

8%

1.6

8%

1.1

4%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

Medical Condition

RHD : 47.8%

HT: 31%

CAD: 27%

HF: 18%

DM: 16%

Non rheumatic VHD: 5.2%

Rheumatic heart disease was the commonest cause of AF

being present in appx. 48% of patients

Underlying Aetiology in Patients with Atrial Fibrillation

The worst thing about AF is not AF, but ISCHAEMIC STROKE

• AF increases the risk of stroke by 5 fold1

• Risk of stroke in AF patients is regardless of the type of AF (paroxysmal or sustained AF)2,3,4 determined

by comorbidities of the patient

• Stroke assessment by CHADS2 and CHA2DS2-VASc5

1. Savelieva I, et al. Ann Med. 2007;39:371-391. 2. Rosamond W, et al. Circulation. 2008;117:e25-146. 3. Hart RG, et al. J Am Coll Cardiol. 2000;35:183-187. 4. Flaker GC, et al. Am Heart J. 2005;149:657-663. 5. Camm AJ, et al. EHJ. 2010;31:2369-2429.

Atrial fibrillation in the 21st century The problem:

• AF is a disease of aging

• Lifetime incidence is 25%

• AF often diminishes quality of life ; it is also an important cause of stroke ( 20%-25% of all strokes) and stroke is the only manifestation of AF in many elderly patients

The solution:

• Stroke is largely preventable !

HOW DO WE APPROACH THIS ISSUE?

Good News: Warfarin is very effective at preventing stroke

WELL-CONTROLLED WARFARIN is a MORE EFFECTIVE treatment for stroke prevention in AF than other treatment strategies !

1. Hart RG, et al. Ann Intern Med. 2007;146:857-67. 2. ACTIVE Investigators. Lancet. 2006;367:1903-1912. 3. SPAF Investigators. Lancet. 1996;348:633-638.

Bad News: Warfarin is not used very well, in part due to its limitations

Because of several limitations with warfarin, the risks often outweigh benefits

1. Ansell J, et al. Chest. 2008;133;160S-198S. 2. Umer Ushman MH, et al. J Interv Card Electrophysiol. 2008;22:129-137. 3. Nutescu EA, et al. Cardiol Clin. 2008; 26:169-187.

Unpredictable response

Routine coagulation

monitoring

Slow onset/offset

of action

Warfarin resistance

CYP 2C9, VKORC1 genetic

polymorphisms

VKA therapy has

several

limitations that

make it difficult

to use in

practice

Numerous drug-drug

interactions

Numerous food-drug

interactions

Frequent dose

adjustments

Narrow therapeutic

window

(INR range 2-3)

Intracranial

bleeding

Drug and Food Interaction

Food-drug interactions: coumadin and vitamin K. http://nursing.uchc.edu/Pharmacy/docs/NUTRITION-COUMADIN.pdf. Accessed June 11, 2011.

Moderate Vitamin K Low Vitamin K

Avoc ado

Beans pod , raw

Broc c oli Ca bbage (white, red ),

Chickpeas

Cuc umbers with skin

Green Onions

Lentils

Lettuc e

Liver

Sa lad oils inc lud ing c anola , soybean, o live

Mayonna ise made from c anola or soybean

oil

Pic kles

Pistac hio nuts

Snack c hips c onta ining Olestra

Soybeans, tofu

Spinac h

Asparagus

Beets

Bean sprouts

Carrots Cauliflower

Corn

Green beans

Green peppers

Peeled c uc umbers

Mushrooms

Onions

Peas

Pota toes

Sweet pota toes

Bread , ric e, pasta , other gra ins

Fruit

Da iry foods

Meat Fish

Poultry

Only 38% of the eligible patients are put on OAC in spite of guideline recommendations

Healey JS et al. ESC Congress 2011

CHADS2: Congestive Heart Failure, Hypertension, Age ≥75, Diabetes Mellitus, Prior Stroke or TIA (2)

New Oral Anticoagulants

Common

Pa thway

IX X

TF VIIa

VIII

Xa

Thrombin

Fib rin

Thrombin

Ac tivity

Initia tion

Phase

Amplific a tion

Propagation

Phase

Pla telet

Surfac e

XII

XI

Contact

Fib rinogen

Da b iga tran2

etexila te

Rivaroxa ban1

Ap ixa ban

Warfa rin

1. Maha ffey KW et a l. Presented a t AHA 2010; Session LBCT02 21839; Ava ilab le a t: http :/ / sc ienc enews.myameric anheart.org / sessions/ la te_b reaking .shtml#roc ket . 2. Eikelboom J, et a l. J Am Coll Ca rd iol. 2003;41:70S–78S.

21

The Newer Anticoagulants on the Horizon Trial

Drug Dose Comparator N CHADS2

score

RE-LY Da b iga tran

150 mg and

110 mg*

BID

Warfa rin

(INR 2.0–3.0) 18,113 >0

ROCKET-AF5,6 Rivaroxa ban 20 mg*

OD

Warfa rin

(INR 2.0–3.0) 14,264 ≥2

AVERROES3,4 Ap ixa ban 5 mg

BID

Asp irin

(81–324 mg OD) 6000 ≥1

ARISTOTLE1,2 Ap ixa ban 5 mg

BID

Warfa rin

(INR 2.0–3.0) 18,201 ≥1

ENGAGE-AF TIMI

487 Edoxa ban 30 mg OD

60 mg OD

Warfa rin

(INR 2.0–3.0) >20,000 ≥2

*Ad justed based on rena l func tion. BID, twic e da ily; INR, interna tiona l norma lised ra tio; OD, onc e da ily

Left Atrial Appendage Closure

91% Thrombi Originate in LAA

Warfarin: High Efficacy

1. Hart RG et al. Ann Intern Med. 2007;146:857-867;

2. CCS 2012 AF Guidelines Can J Cardiol . 2012; 28:125-136

Effect of VKA compared to placebo

Stroke Death

67% 26%