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Taking heart for the future of AF and stroke prevention

Atrial fibrillation (AF) has emerged as one of the most insidious threats to health and the risks are compounded by an increasingly ageing population.

This ageing population is expected to double in Europe by 2060 and aside from the potentially devastating consequences for patients of stroke arising from AF, this will place enormous pressures on health services throughout the continent. It will also represent a rise in the number of people with AF from 8.8 million to some 17.9 million.

In Ireland, the Irish Heart Foundation states that AF affects up to 40,000 people and this figure includes 6 per cent of the over-65 year-old population. Approximately 30 per cent of strokes in Ireland are associated with AF, which equates to more than 2,500 people each year, and AF increases stroke risk by five-fold, according to the Foundation.

The report — titled The Future of Anticoagulation: An Assessment of Today’s Challenges with Recommendations for the Future — was unveiled at a special launch meeting in Brussels recently to coincide with Heart Rhythm Week, which ran from 1-7 June. The report was written and researched by RAND Europe and supported by Daiichi Sankyo Europe.

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Prof John Camm

A distinguished list of speakers, all respective experts in their fields, addressed the delegates at the launch. This panel included Prof John Camm, Professor of Clinical Cardiology at St George’s Hospital, University of London, UK; Dr Roberto Bertollini, Chief Scientist and WHO Representative to the European Union; Prof Joanna Chataway, Research Group Director, Innovation, Health and Science, RAND Group; and Ms Trudie C Lobban MBE, Founder and CEO of the Atrial Fibrillation Association.

RAND Europe is a not-for-profit research institute whose mission is to help improve policy and decision-making through research and analysis.

Prof Camm, who Chaired the event, began by explaining: “Although there are many dimensions to the management of complicated cardiac rhythm disturbance, the ‘low-hanging fruit’, the thing we can really do to improve the outcome for patients with this condition, is to make sure that they are appropriately anticoagulated,” he told the attendees, adding that as many of 50 per cent of AF patients are asymptomatic and have no idea that they have the condition.

Others, he continued, live with extreme anxiety because of an irregular heartbeat and as many as 50 per cent of patients who suffer an AF-related stroke die within one year. “Most of the remainder are severely disabled,” he added.

In terms of prevalence, somewhere between 0.5 and 2 per cent of the general population have AF, Prof Camm continued. “Until a few years ago, it was thought to be less than 1 per cent but when we actually started purposely looking for it, it became apparent that the figure is much greater than 1 per cent and if we continue to look for it in populations, in the next year or two it will probably end up at about 3 per cent.”

He cited the ageing population and noted that AF is at its highest prevalence in people in their 70s and 80s, where AF approaches 15-to-20 per cent in this demographic. “A statistic that should impact on all of us is that at least one out of four of us will have AF before we die,” he told the attendees. “Taking into account the ageing population, it is calculated that by 2060 the figure will be at least 3-to-3.5 per cent of the general population with AF.”

The objectives of the report are to help understand how to manage and contain this growing healthcare issue and to detect AF, manage it, try to prevent it in the general population and treat people with the condition.

Urgency

“There is a sense of urgency around this,” Prof Camm continued. “We have been trying for some years to persuade policy-makers to try to appreciate that this is a really serious problem. With a very small expense, we can actually prevent a large volume of disease in terms of all those patients who have suffered a stroke. There have been previous initiatives, but this report is the next step along that path.”

The next speaker, Dr Bertollini, took to the podium to speak on “the epidemic of non-communicable diseases”.

“The situation is particularly serious in Europe and the US, where the proportion of burden attributable to non-communicable diseases is larger than in other areas of the world. However, I want to point out that in absolute terms, the situation is changing,” Dr Bertollini told the launch attendees.

“The epidemic of non-communicable disease is actually starting to create problems and concerns and causes disease and disability in other parts of the world also — some 75 or 80 per cent of non-communicable disease in the world is actually coming from low- and middle-income countries.”

Dr Bertollini presented data to illustrate the disparities in rates of disease across Europe, emphasising the prevalence of cardiovascular diseases and providing a European overview. “The situation is evolving… the situation is deteriorating in the Eastern part of Europe, the former Soviet Union,” he said. “But there are problems in terms of [rates of] cardiovascular disease across Europe, East and West. There is extremely high heterogeneity in different countries within the European Union and this is also true for cerebrovascular diseases, so we are talking about a very significant problem in terms of mortality and disability.”

Although there are many dimensions to the management of complicated cardiac rhythm disturbance, the ‘low-hanging fruit’, the thing we can really do to improve outcomes, is make sure patients are appropriately coagulated

He continued: “In the countries where rates of disease are highest, there are a number of causes implicated but behavioural factors such as diet and physical activity are also important. This is something of particular concern for us and one of the main objectives of our strategy at the moment is to address health inequalities.”

Referring to the figures which show that AF rates are set to double by the year 2060, Dr Bertollini explained: “These projections assume a ‘business as usual’ situation but if there are interventions, management and preventive measures… we hope that delivering this strategy will make a difference.”

Before the next assessment of rates of non-communicable disease, some of the measures the WHO is aiming for include reduction of tobacco consumption by 30 per cent, reduction of salt intake by 30 per cent, reduction of blood pressure by 25 per cent and increase in physical activity by at least 10 per cent. He said the Organisation is also aiming to introduce as many measures as possible to halt the obesity epidemic.

“But sometimes, simple interventions can be very complex to implement,” he told the attendees, referring to dealings with food manufacturers. “Also, politically, sometimes the mandate of a minister can be for only one year but if this is four or five years, they can try to make a real difference.”

Prof Chataway was next to take to the podium and began by outlining RAND’s contribution to the report. “We got involved in this initiative because anticoagulation related to AF is a growing concern in Europe and RAND has a lot of experience in futures analysis and policy research and we thought this was a good opportunity to feed into the debate and decision-making around anticoagulation and AF policy.”

New treatments

She explained that the researchers took a pan-European perspective for the report and looked at the implications of AF across different healthcare systems. “Education of patients and healthcare providers was shown to be important,” Prof Chataway told the attendees. “Another important factor is the development of new treatments, such as the non-vitamin K antagonists which have come onto the market, as well as antidotes that are in development and digital monitoring devices. These will be an increasing part of the landscape over the next five-to-10 years.”

She explained that AF is currently under-diagnosed: “That’s a main message from this report,” she said. “A significant proportion of AF patients are identified completely by chance during health checks or, unfortunately, after the occurrence of a stroke. Opportunistic screening does take place, but not to the extent that it could.”

Prof Chataway addressed treatment options and the importance of prevention of strokes due to AF. “The uptake of novel oral anticoagulants (NOACs) varies across the regions but the under-use of NOACs came across as a feature of the study and in terms of patients at low risk, over-use could be an issue sometimes.”

She identified low awareness of AF as one of the challenges to treatment, along with obtaining funding for awareness campaigns to help educate asymptomatic patients. Awareness in the healthcare community beyond GPs is also an issue, said Prof Chataway.

On an organisational level, she cited the need for policy-makers to be aware of the overall costs of AF, not just in terms of hospitalisation costs, but also the significant burden of post-hospitalisation care for stroke patients.

Ms Lobban then addressed the launch to offer the patient perspective, in an effort to help attendees understand the personal burden of AF and stroke related to the condition. “Approximately six million Europeans have AF and that increases stroke risk five-fold, resulting in stroke affecting about 9.6 million Europeans,” she said.

“Most of us here will either develop AF or care for someone with AF, so it’s very important for us all to pay attention today and make changes, not just for the people who have AF today, but for ourselves and our loved ones in the future.”

Without intervention, Ms Lobban explained, 5-to-8 per cent of AF patients will suffer a stroke within one year: “But this is something that we can actually do something about — we can actually change that using anticoagulation.”

She continued: “Our key message is ‘Detect’ (AF), ‘Protect’ (against stroke) and ‘Correct’ (the heart rhythm)’ when it comes to cardiac arrhythmia… we encourage patients to try to take responsibility by checking their own pulse or if they are unsure, to visit their doctor for a check-up.” She outlined the emotional and financial burden for AF-related stroke patients and described the personal turbulence experienced by AF patients following diagnosis, which is often followed by renewed hope when they learn that the condition is treatable.

“We need timely and accurate diagnosis for these people,” she told the attendees. “We also need reliable, helpful information and easy access to appropriate treatment and a joined-up care pathway. We hope that having all these people together today will help to increase the spread of that message.”

Advances

Speaking to the Medical Independent (MI), Prof Camm highlighted the importance of treatment advances in improving mortality rates and quality of life for AF patients. “The new medications available are much easier for the patient to take because they do not need to make any extensive change in their lifestyles,” he says.

“For example, they don’t have to be careful [about interactions] with other medications for the most part and there are no interactions with food, so they don’t have to stick to a special diet and they don’t have to go for regular testing, so hospital visits are greatly reduced.”

He explained that in the broader context, this can take significant pressures off hospital systems and healthcare resources. “The use of these NOACs is associated with fewer strokes, so you don’t have the knock-on effect of all those downstream strokes and the costs that these involve for health services,” he tells MI. “Also, in terms of post-hospital care, those who survive strokes can have serious disabilities and this is also very expensive.”

He also reveals that he himself was diagnosed with AF at the age of 30, illustrating the fact that the condition can manifest at any age, also meaning that he can fully relate to patients, as “at least I know what it’s like for them”.

“The main point that we were trying to address [with the report launch] is trying to get healthcare systems, and in particular the EU, to realise that strokes due to AF are numerous but can be very effectively treated. Nowadays, diagnosis and treatment are very cost-effective,” he concludes. “If we can get doctors to do the tests and use these medicines, we would reduce the terrible distress caused by stroke due to AF — and that’s the main message.”

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