Warfarin in decline, alternatives on the Up?
Pulse magazine is reporting that GPs are increasingly prescribing the newer anticoagulant alternatives to warfarin for the prevention of stroke, although their uptake has been slower than expected due to cost concerns.
An analysis of NHS primary care prescribing data for the past three years shows a fourteen-fold increase in the use of the newer anticoagulants dabigatran, rivaroxaban and apixaban in 2012, compared with 2011.
There was also a 9% increase in the use of warfarin from 2011 to 2012, leading experts to conclude that newer anticoagulants are being reserved for patients who are unsuitable for warfarin.
Pulse reported last year that following the NICE approval of dabigatran in March for certain patients with atrial fibrillation, CCGs put restrictions in place to limit use of the drug, with some warning its use as an alternative to warfarin could ramp up primary care drug budgets by as much as 20%.
This looks to have put a lid on demand, alongside concerns about the safety profile of some of the newer alternatives.
The figures from the NHS Information Centre Prescribing and Primary Care Services show that the total number of NHS prescriptions in 2012 for warfarin rose to 10.2 million prescriptions dispensed last year, compared with 9.4 million in 2011.
The total prescribed items for dabigatran – including those prescribed in patients with atrial fibrillation and venous thromboembolism – went up from around 3,200 in 2011, to 48,300 in 2012. Prescriptions for rivaroxaban and apixaban also rose, but their use remains much lower than that of dabigatran.
To read the full article from Pulse click here
Ivabradine (Procorolan) for Heart Failure
The National Institute for Health and Clinical Excellence (NICE) is issuing final draft guidance recommending ivabradine (Procoralan) as a treatment option for some people with chronic heart failure.
Treatment for heart failure is designed to help improve life expectancy, quality of life and to avoid hospital admissions. We feel this decision is long overdue and is great news for some patients.
The heart-rate-lowering drug ivabradine significantly reduced the risk of cardiovascular death and hospital admissions for worsening heart failure when added to standard treatment in patients, according to a UK, US and European study in 2010.
The ‘Systolic Heart Failure treatment with the ivabradine Trial’, known as SHIFT, looked at whether lowering heart rate with ivabradine reduces cardiovascular death and admission to hospital.
The patients studied had worsening heart failure, chronic heart failure, systolic dysfunction and a high heart rate over 70 beats per minute (bpm) or higher.
6,505 patients from 37 countries were studied over around 23 months. Around half were randomly given ivabradine twice daily in addition to standard heart failure treatments. The other half had a dummy placebo treatment added instead.
Treatment with ivabradine significantly reduced the risk of major heart failure by 18% compared to the dummy treatment. 16% of patients taking ivabradine were admitted to hospital with worsening heart failure compared to 21% in the placebo group. 3% of patients in the group taking ivabradine died from heart failure compared to 5% taking the placebo.
Ivabradine brought about an average reduction in heart rate of 15 bpm.
Who would get the new treatment?
The new guidance covers ivabradine for people with classes of chronic heart failure called NYHA class II to IV and other restrictions. The new guidance says ivabradine is cost effective when used in combination with standard therapy, including beta-blockers, angiotensin-converting enzyme (ACE) inhibitors and aldosterone antagonists, or when beta-blockers are not appropriate.
The decision to use ivabradine would be taken by a heart failure specialist. The treatment would cost the NHS around £42 per patient a month.
For this cost compared to a hospital admission makes economic sense. Be aware if you have AF then ivabradine will not be prescribed.
Heart arrhythmia AF and alcohol
New research has been published in the Canadian Medical Association Journal.
People with heart disease who drink, even moderately, may have a slightly increased risk of a common heart rhythm problem, a new study suggests. The study is not the first to link moderate drinking to the heart arrhythmia, known as atrial fibrillation (AF). But it’s still not clear that the habit, itself, is the problem.
Doctors have long known that a drinking binge can trigger an episode of AF, in which the heart’s upper chambers begin to quiver instead of contracting normally. In general, it’s thought that having one or two drinks per day is protective against coronary heart disease – where cholesterol-containing “plaque” builds up in the arteries. But modest drinking hasn’t been linked to a decreased risk of AF – and the new findings suggest that when people already have heart issues, moderate drinking is actually tied to more AF cases.
The study included more than 30,000 older adults who either had clogged arteries, a history of stroke or diabetes complications such as kidney disease. Most had coronary heart disease.
Over about five years, people who drank occasionally or not at all developed AF at a rate of about 1.5% each year. For moderate drinkers, the rate was 1.75 and for heavy drinkers, it was 2.1%.
The researchers looked at other factors, too – like age, weight and smoking habits. But moderate drinking was still linked to a 14% increase in the risk of AF.
“Recommendations about the protective effects of moderate alcohol intake in patients at high risk of cardiovascular disease may need to be tempered with these findings,” write the researchers, led by Dr. Yan Liang, of McMaster University in Hamilton, Ontario. Still, a researcher not involved in the work doubted the link between moderate drinking and AF.
One problem is separating out the effects of binge drinking, according to Dr. Kenneth J. Mukamal, of Harvard University and Beth Israel Deaconess Medical Center in Boston.
Liang and colleagues did do a separate analysis where they excluded people who reported a history of binge drinking – having more than five drinks at a time. And the results were similar. But, Mukamal said in an email, the study did not repeatedly measure binge drinking habits over the five-year follow-up. So it’s impossible to know if moderate drinkers’ AF episodes were related to binges. “The majority of binge-drinking episodes nationwide occur among otherwise moderate drinkers,” Mukamal noted. What’s more, he said, the current study included patients who were involved in two clinical trials testing blood pressure drugs. That’s a narrow group of people. “In large studies of general populations - much more representative than these clinical trial participants – AF only appears higher among heavy drinkers,” Mukamal said.
Atrial fibrillation arises from a problem in the heart muscle’s electrical activity. It’s not immediately life-threatening, and in some cases, an AF episode is short-lived and goes away on its own. The known risk factors for AF include older age, high blood pressure, diabetes, obesity and hyperthyroidism.
According to Mukamal, it’s not surprising that moderate drinking seems to offer no protection against AF. The ways in which alcohol might cut the risk of coronary heart disease - through better “good” cholesterol levels and less blood clotting – don’t affect the risk of developing AF.
In general, experts say that if you’re already a moderate drinker (up to one drink a day for women, and two for men), it’s probably okay to keep it up. But for people with certain chronic health problems, the new results may question that guidance, the researchers said.
“And binge drinking should be avoided, even if you drink infrequently.”
This article talks through the effects of intensive and prolonged exercise without recuperation and shouldn’t be confused with regular exercise.
Too much exercise can scar the heart and increase the risk of sudden death, experts claim. Research shows that extreme endurance sports such as marathons, triathlons and long-distance bicycle races can cause structural changes to the heart and large arteries.
Usually recovery occurs within a week. But for some individuals, repetitive injury over months and years of training and competition can lead to patches of fibrosis, or scarring, in the heart, say scientists. This can lead to an increased likelihood of potentially fatal abnormal heart rhythms.
Dr James O’Keefe, from Saint Luke’s Hospital in Kansas City, US, who led a review of the evidence, said: “Physical exercise, though not a drug, possesses many traits of a powerful pharmacologic agent. A routine of daily physical activity can be highly effective for prevention and treatment of many diseases, including coronary heart disease, hypertension, heart failure, and obesity.
“However, as with any pharmacologic agent, a safe upper-dose limit potentially exists, beyond which the adverse effects of physical exercise, such as musculoskeletal trauma and cardiovascular stress, may outweigh its benefits.” The research is published in the June issue of Mayo Clinic Proceedings.
Endurance sports such as ultramarathon running or professional cycling have been associated with as much as a five-fold increased risk of atrial fibrillation, one kind of abnormal heart rhythm, say the scientists. Excessive sustained exercise may also be linked to coronary artery calcification, and dysfunctional and stiffened large arteries.
One study showed that around 12% of apparently healthy marathon runners had signs of heart scarring. Their chances of suffering a heart-disease event was also significantly higher than average. A famous victim of excess exercise may have been legendary US ultramarathon runner Micah True who died suddenly while on a routine 12-mile training run on March 27, it is claimed. True, nicknamed Caballo Blanco (Spanish for “white horse”), would run as much as 100 miles in one day. After death at 58, his heart was found to be enlarged and scarred. He died from a lethal heart rhythm irregularity.
Guest Blog – AF Association (Part 3 of 3)
So who are the Atrial Fibrillation Association?
The Atrial Fibrillation Association (AFA) is a UK registered charity that focuses on raising awareness of Atrial Fibrillation (AF) by providing information and support materials for patients and medical professionals involved in detecting, diagnosing and managing Atrial Fibrillation. There is now also a sister charity in the US, Atrial Fibrillation Association USA.
All information booklets published by AFA have been approved by an AF medical panel and endorsed by the Department of Health. The booklets currently available include titles on: Cardioversion of AF, Drug Treatments for AF, Blood Thinning for AF, two Checklists and an AF Patient Information booklet. They are downloadable from the AFA website.
AFA aims to provide support and information on Atrial Fibrillation to those affected by this condition; to advance the education of the medical profession and the general public on the subject of Atrial Fibrillation and to promote research into the management of condition.
The charity is involved in several campaigns for AF and heart rhythm disorders including World Heart Rhythm Week, ACT on AF and Know Your Pulse.
Its website, www.afa-international.org provides a wealth of information for patients and professionals including links to UK and international AF specialists.
Guest Blog – Atrail Fibrillation Association
Diagnosing & Treating AF (part 2 of 3 guest blogs about AF)
The simplest way to detect AF is to feel a pulse. If the rhythm of the beat seems irregular, this may indicate AF. However it is very important to check this with a doctor and to find out whether you do actually have AF. If a clinician suspects you have Atrial Fibrillation, they will arrange for you to have an ECG (electrocardiogram). An ECG is painless and records the electrical activity of your heart. Usually this is carried out in a GP surgery or at a local hospital, however, if your episodes ‘come and go’, you may be given a monitor – this is worn (simply taped to your chest) for 24 hours or more, and continuously records the electrical activities of your heart.
When the monitor is returned the clinician can download the information and assess it. The heart rhythm can be diagnosed with certainty and possible underlying heart problems may often be detected.
Following the ECG, and if you are diagnosed as having Atrial Fibrillation, you may need to have an echocardiogram (a scan) which can assess the structure and overall function of the heart. This test is painless and without any risk to a patient. The results from this test will tell the physician about heart muscle disease (thickening or thinning), the size of the main pumping chambers, and the state of the heart valves, any of which might have aggravated the heart rhythm abnormality.
A variety of blood tests may be needed, depending on the individual’s medical history. In almost all cases, the activity of the thyroid gland will be measured through a blood sample, because over activity may provoke AF.
Free, medically approved and endorsed patient information can be ordered or down loaded from Atrial Fibrillation Association
If a patient has suffered chest pain, a marker of heart muscle damage (troponin) is often measured. If a patient is taking any other medication or has underlying heart disease or has any other medical problems, suitable tests will also be carried out.
Once Atrial Fibrillation has been diagnosed, there are a number of treatments available. The mainstay of treatment of AF is with drug therapies. Other non-drug therapies such as pacemakers and ablation therapies are reserved for certain subsets of AF patients. The drugs used to restore the normal heart rhythm are known as anti-arrhythmic drugs. They work by blocking specific channels in the cardiac cell. Anti-arrhythmic drugs comprise different drug classes and have different modes of action. Moreover, someclasses and even certain drugs within a class are effective for particular rhythm disturbances. Some drugs, aim for Rhythm Control, that is, to restore and maintain normal rhythm but can have troublesome side-effects.
Another type of drug such as beta-blockers aim for Rate Control. This means slowing the irregular heart rate without attempting to restore the normal heart rhythm. Rate control is not inferior to rhythm control and is an attractive alternative in patients with a high risk of AF recurrence. In less active patients, other rate control drugs, such as digoxin can be used. Combinations of digoxin and beta blockers or calcium antagonists may be required to achieve effective rate control. Amiodarone is often used for rate control in AF when its rhythm control efficacy has been exhausted. However, given its significant side effect profile, it is not routinely used for rate control.
Unfortunately, there is no “one size fits all” answer to the management of AF. Multiple drugs may be tried and adjusted until one is found that achieves the desired goal of optimal rate or rhythm control with minimal side effects.
Recently several new drugs have been approved for use with AF. One, Pradaxa, also known as Dabigatran, prevents blood clots which cause stroke, which is a risk for people with AF. There are also surgical interventions for AF such as Catheter Ablation and Cardioversion. Cardioversion is suitable for those recently diagnosed while Ablation is reserved for those with intrusive symptoms that impact significantly on quality of life, are refractory to treatment with medication or where medical therapy is contraindicated because of other conditions or intolerance.
Heart failure caused the death of 1970s disco icon Bobby Farrell in a Saint Petersburg hotel room this week, his agent said Friday citing Russian authorities.
“It was heart failure,” agent John Seine told AFP by telephone from the northern Dutch town of Heemstede.
Steine said he had received an email Friday lunchtime from Euromed, a medical institution holding Farrell’s body in a Saint Petersburg mortuary, to report the findings of a post-mortem investigation by Russian authorities.
Farrell, 61, was found dead in his bed by a hotel employee on Thursday morning, having given a performance the night before during which he reported feeling unwell.
The group sold more than 50 million singles and 60 million albums worldwide.
Cardioversion here we come
Just had my initial consultation with Angela Graves my Heart Failure Nurse and Dr John McDonald my cardio consultant who has just set the date for for my Cardioversion.
Can’t say I am completely looking forward to it, I still have an aversion to needles when I have my general anaesthetic but I realise that it could take me out of AF and back into Sinus Rhythm so I suppose this is a really good thing. The only big decision I had to make was taking Amiodarone.
Amiodarone is an Anti-Arrhythmic drug that has some quite perturbing side effects and I will let you investigate that. It has a half life of 45 days which means in layman’s terms it doesn’t get into your body for 45 days and therefore takes a long time to exit as well. Therefore John McDonald and I have agreed that I start off on 200mg of Amiodarone and continue this until I get my Cardioversion on the 25th November, if I don’t make it into to Sinus Rhythm and stay in AF then I will come off Amiodarone or if I go into Sinus Rhythm then I stay on Amiodarone for 90 days and no more. This is to enable my heart to have the best possible chance of staying in Sinus Rhythm. The reason for taking the Amiodarone before Cardioversion is that it increases the chances by 15-20% of the heart going into sinus rhythm from an electrical Cardioversion. It then keeps the heart stable by trying to prevent a flip over to AF again.
What I will stress is that to have these levels of discussion you need to have the right relationship with your Consultant and Nurse. Both John and Angela are very supportive but probably think I ask too many questions. Because I challenge my clinicians I am an expert patient – you should try it.
Understanding Atrial Fibrillation
At Pumping Marvellous we try to keep things simple as we are patients, however we do know a fair bit about our conditions so we do like to share our experiences with our readers. Sometimes it can become a little technical even for us with the conditions and we may need to use reference points to help us be factual but as stated we try to keep things simple.
Atrial fibrillation is a heart condition that causes episodes of irregular and often abnormally fast heart rate.
A normal heart rate should be between 60 and 100 beats a minute at rest. You can measure your heart rate by feeling the pulse in your wrist or neck. In atrial fibrillation, the heart rate may be over 140 beats a minute.
There are three main types of atrial fibrillation:
* Paroxysmal atrial fibrillation. This comes and goes and usually stops within 48 hours without any treatment.
* Persistent atrial fibrillation. This lasts for longer than seven days (or less when it is treated).
* Longstanding persistent atrial fibrillation. This usually lasts for longer than a year.
When the heart beats normally, its muscular walls contract (tighten and squeeze) to force blood out and around the body. They then relax, so the heart can fill with blood again. This process is repeated every time the heart beats.
In atrial fibrillation, the upper chambers of the heart (atria) contract randomly and sometimes so fast that the heart muscle cannot relax properly between contractions.
This may lead to a number of problems, including dizziness and shortness of breath. You may also be aware of a fast and irregular heartbeat (palpitations) and feel very tired.
Some people with atrial fibrillation have no symptoms and are completely unaware that their heart rate is not regular.
So why does it happens
Atrial fibrillation occurs when abnormal electrical impulses suddenly start firing in the atria. These impulses override the heart’s natural pacemaker, which can no longer control the rhythm of the heart. This causes you to have a highly irregular pulse rate.
The cause is not fully understood, but it tends to occur in certain groups of people and may be triggered by certain situations, such as drinking excessive amounts of alcohol or smoking.
How common is it?
Atrial fibrillation is the most common heart rhythm disturbance and affects up to 500,000 people in the UK.
Who is affected?
Atrial fibrillation can affect adults of any age, but affects men more than women and becomes more common the older you get. It affects about 10% of people over 75.
Atrial fibrillation is more likely to occur in people with other conditions, such as high blood pressure or atherosclerosis.
It is not common in younger people unless they have a heart condition.
Atrial fibrillation is generally not life threatening, but it can be uncomfortable and often needs treating.
Treatment may involve medication to control heart rate and/or rhythm, and medication to prevent stroke.
A healthy lifestyle, regular blood pressure checks and treatment for raised blood pressure can reduce the chances of developing the heart problems that cause atrial fibrillation.
AF and Dronedarone
This is a recent press release from NICE (National Institute for Health and Clinical Evidence). It talks through it’s recommendation of Dronedarone which is a derivative of Amiodarone which is an antiarrythmic drug. It is quite technically but is an interesting read.
“In guidance published today NICE recommends the use of dronedarone as a second-line treatment in people with additional cardiovascular risk factors whose atrial fibrillation (AF) has not been controlled by first-line therapy (usually including beta-blockers). The guidance recommends dronedarone as an option for the treatment of non-permanent atrial fibrillation only in people:
Whose atrial fibrillation is not controlled by first-line therapy (usually including beta-blockers), that is, as a second-line treatment option, and
– who have at least one of the following cardiovascular risk factors:
– hypertension requiring drugs of at least two different classes
– diabetes mellitus
– previous transient ischaemic attack, stroke or systemic embolism
– left atrial diameter of 50 mm or greater
– left ventricular ejection fraction less than 40% (noting that the summary of product characteristics [SPC] does not recommend dronedarone for people with left ventricular ejection fraction less than 35% because of limited experience of using it in this group) or
– age 70 years or older, and
– who do not have unstable New York Heart Association (NYHA) class III or IV heart failure1.
In recommending the use of dronedarone as a treatment option for some people with AF, the independent Appraisal Committee noted comments from patients and clinical experts received during consultation on the draft guidance that all current anti-arrhythmic drugs have side effects which can have a significant impact on quality of life with long term use. It heard from patient experts that some people with atrial fibrillation might prefer to take dronedarone because it has fewer side effects, despite it being less effective than other antiarrhythmic drugs in preventing recurrence of atrial fibrillation. The committee also accepted evidence that the drug did not lead to an increase in the risk of mortality, unlike the anti-arrhythmics with which it was compared.
Atrial fibrillation is one of the most common heart rhythm disturbance conditions. It can cause symptoms such as palpitations and tiredness and is associated with an increased risk of thrombus (blood clot) formation and thromboembolism including ischaemic strokes. The prevalence of AF increases with age and in the UK nearly 50,000 new cases of AF are diagnosed each year. Standard baseline therapy for AF may include drugs to maintain sinus rhythm, where beta-blockers are usually the first choice.”