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
Fish oils and Atrial Fibrillation
It is important you read this report in context that the information only pertains to preventing AF in patients who have had an AF diagnosis with fish oils. There are lots of other benefits to individuals who take omega-3 fish oils.
The study, published in the Journal of the American College of Cardiology.
“The results for atrial fibrillation are important negative findings, answering key clinical and research questions,” said Dr. Dariush Mozaffarian, an omega-3 expert at the Harvard School of Public Health, who was not involved in the study.
The new research, combined with other trials, “indicates that short-term fish oil use is unlikely to prevent recurrent atrial fibrillation,” he said.
Atrial fibrillation, in which the heart’s upper chambers beat out of step with those below. The condition is linked to strokes and heart failure.
Although doctors prescribe certain medications to treat the condition, none to date has proven particularly effective. As a result, most drug treatment focuses on preventing strokes by administering blood thinners to dissolve clots caused by the fibrillation.
Some evidence suggests that omega-3 fatty acids, found in oily fish like sardines and tuna, might reduce the risk of atrial fibrillation, although exactly how they would produce their effect is not clear.
A study published earlier this year in Circulation, for example, found that people with the most omega-3s in their blood had a 30% lower chance of developing an irregular heart beat than those with the lowest concentrations of the substances.
That 30% difference would work out to eight fewer cases of atrial fibrillation per 100 people – which would be a meaningful benefit if it could be enjoyed by those with fibrillation or at risk for it, just by consuming more omega 3s.
But the latest study suggests that it probably can’t. The trial included 586 men and women with a history of atrial fibrillation who were given a gram a day of fish oil or dummy capsules for a year. Participants also were allowed to take other drugs to control their heart rhythms, as prescribed by their doctors.
At the end of the study period, about 24% of the people who took fish oil, and 20% of those who did not, had experienced a recurrence of atrial fibrillation – a difference so small, statistically, it was likely due to chance.
The findings on atrial fibrillation echo results from a study led by Mozaffarian published in November, of patients recovering from heart surgery.
Even so, Dr. Alejandro Macchia, a cardiologist at the GESICA Foundation in Buenos Aires, who led the current study and collaborated with Mozaffarian on the previous one, said fish oil may still prove beneficial for heart health, at least in some patients.
Questions about Digoxin
We think it would be prudent to get a balanced report on the latest on Digoxin and it’s links to Deaths with people with Atrial Fibrillation which is a heart rhythm condition as these reports tend to have a habit of spreading like a wild fire and by the time you hear of it the message has been put on the grapevine and the real messages have fallen off the cliff!
The study, which was published online in the European Heart Journal on Nov. 27, 2012, showed that patients who took digoxin who had atrial fibrillation (AF) died in significant numbers whilst on the medication.
Digoxin is made from an extract from the foxglove plant used on patients who have AF and heart failure. Theoretically, it makes the heart beat stronger and more regularly. It is notoriously hard to use because there is a narrow dose range between where it is helpful and when it can cause harm. High doses have been seen to increase death in patients.
For the study, researchers looked at data from 4,060 AF patients who took digoxin before or during the 3.5 year study. The subjects had all enrolled in the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) to determine any affects digoxin had on increased death rates.
Digoxin was associated with a 41% increase in deaths from any cause, after controlling for other factors. Patients who took digoxin also had a 35 percent increase in deaths from cardiovascular causes, and a 61 percent increase in deaths from arrhythmias, or problems with heart rate.
“These results mean that among AF patients taking digoxin compared to those not on digoxin in the AFFIRM trial, within five years one additional patient out of six will die from any cause, one additional patient out of eight will die from cardiovascular causes, and one additional patient out of 16 will die from arrhythmias,” Samy Claude Elayi, associate professor of medicine at the Gill Heart Institute, University of Kentucky, in Lexington said in a press release.
Elayi added that the results show that widespread use of dioxin may be detrimental to patients who are suffering from AF. However, the findings do not show that the medication is bad for everyone he pointed out to Reuters.
“But in patients that have no heart failure and (have) atrial fibrillation, I think there is no reason to use this drug as a first line,” Elayi said.
Dr. Ali Ahmed, who has studied digoxin at the University of Alabama at Birmingham, told Reuters in a later statement that the study was flawed because it was looking for problems caused by digoxin and did not assign people blindly to the study. He said other “…other patient diseases may have caused the deaths.
“This should be taken with extreme caution, because of the potential for confounding and bias from a variety of sources,” Ahmed, who wasn’t involved in the new research, said.
Natasha Stewart, senior cardiac nurse at the British Heart Foundation (BHF), added to the BBC that while digoxin isn’t the first medication of choice in the U.K., some patients are taking it — and there are plenty of benefits for AF and heart failure patients.
“Before we jump to any conclusions about the dangers of the drug, we’d need to see further research into what might be causing these increased risks,” she said. “Patients who are prescribed digoxin should not stop taking their meds without discussing their concerns with their doctor.”
I think the last statement says it all really and it is important that if you are concerned that you should discuss your concerns with your Doctor or Heart Failure Nurse and not change your medication in anyway unless directed to do so.
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.”
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.
Occasionally we ask complimentary organisations and charities to write information on their speciality. We will be posting 3 guest blogs from the Arrhythmia Alliance on Atrial Fibrillation (AF). We hope you get a lot from these posts as it is a condition that affects a large percentage of Heart Failure Patients. Anyway here goes -
What is Atrial Fibrillation?
Atrial Fibrillation (AF) is the most common heart rhythm disturbance encountered by doctors. It can affect adults of any age, but it is more common as people get older. In the over 65 year old age group, it affects about 10% of people.
Atrial fibrillation is not a life-threatening heart rhythm problem, but it can be troublesome and often requires treatment. It is also a leading risk indicator for stroke. If you have AF, you are five times more likely to experience a stroke. In 2007, Atrial Fibrillation Association (AFA, www.afa-international.org ) was established as a patient support and information charity which offers medically approved and endorsed information for patients, carers and healthcare professionals.
Atrial fibrillation or AF, occurs when chaotic electrical activity develops in the upper chambers or atria, and completely takes over from the sinus node. As a result, the atria no longer beat in an organised way, and pump less efficiently. The AV node will stop some of these very rapid impulses from travelling to the ventricles, but the ventricles will still beat irregularly and possibly rapidly.
The cause of AF is not fully understood and men and women are equally susceptible to the disease. It is also age related – the older you become the more likely you are to develop AF. However, it is noted that AF is more likely to occur in patients who have other heart conditions, such as high blood pressure, coronary artery disease, mitral heart valve disease (caused by rheumatic heart disease, valve problems at birth, or infection) or Congenital heart disease (abnormality of the heart since birth) It can also be associated with thyroid gland disorders, carbon monoxide poisoning or alcohol or drug abuse or misuse.
While your risk of developing AF rises with the above mentioned problems, many people develop AF for no explainable reason. When there is no known cause this is known as ‘Lone AF’. AFA runs regular meetings and Patient Day events, details of which can be found on
Some AF patients do not experience symptoms, and the AF is only discovered at a routine medical examination or after a health problem. However, for those who do, the most common symptoms are:
•Palpitations, (or awareness of the heartbeat), which may be rapid
• Shortness of breath
• Chest pain
In early stages of Af, Atrial Fibrillation is often intermittent, meaning that it can come and go without warning. There may also be long spells between ‘episodes’. In fact, some people in this early stage of AF may not even be aware they have it.
Get back in Rhythm with Barry Manilow
We thought you may like this piece of information as a great number of Heart Failure patients experience Atrial Fibrillation (Afib) or other Heart Rhythm complications. The site is great and really helps with self management of the condition. Just goes to show you are not alone!
Music iconBarry Manilow today revealed his long struggle to manage atrial fibrillation (AFib). He has joined with Sanofi-Avensis the Pharma company that has anti-arrhythmic drugs like Amiodarone and Dronedarone in it’s stable is to kick-off Get Back in Rhythm ™ , a US education campaign to raise awareness about Atrial Fibrillation, and to encourage people to learn more about all the risks of AFib and the importance of keeping the heart in rhythm.
Manilow says “When I first experienced AFib more than 15 years ago, it was really scary, it felt like a fish flopping around in my chest,” said Manilow. “I thought I knew about all the risks, but it turns out I didn’t, so I was really lucky I had such great doctors helping me manage it from the start.”
Atrial Fibrillation is a complex condition and many patients may not recognise the symptoms or the full range of health risks associated with it. This is why Manilow encourages those affected by AFib to visit www.GetBackInRhythm.com, to test their AFib knowledge with the Rhythm IQ quiz, learn more about all the risks of the disease and print a guide. The campaign will also include a public service announcement featuring Manilow to help raise awareness about AFib.
Manilow continues “At first, I kept my AFib private because I didn’t want to acknowledge there was something wrong with my heart. But now I realise a lot of my fans and so many others could be affected, so I want to do all I can to help them take it seriously, understand all the risks of AFib and seek the best care,” admits Manilow. “The bottom line is AFib needs more awareness. Patients need more education. No one should settle for a life out of rhythm.”
The goal of Get Back in Rhythm is to improve the health and well-being of those affected by Atrial Fibrillation. The campaign encourages people to learn more about all the risks of Atrial Fibrillation, and talk with their healthcare provider about how to maintain a normal heart rhythm and manage the disease. wwwGetBackInRhythm.com offers a collection of resources including the Rhythm IQ to test Atrial Fibrillation knowledge, an Atrial Fibrillation Risk Assessment tool and a discussion guide to help patients make the most of their visits with their healthcare providers. In addition, visitors can learn about Atrial Fibrillation patient and singer/songwriter Barry Manilow’s personal experience living with Atrial Fibrillation and see what he’s doing to help others “get back into rhythm.”
It is worthwhile noting that whilst in the UK celebrity endorsed prescriptive pharma products are not allowed however across the rest of the world there are a lot of countries where celebrities endorse prescriptive drugs and Barry Manilow has supported Sanofi-Aventis which produces Droneadorone (Multaq) which has led to the creation of the Rhythm site which is fuly funded by Sanofi-Aventis.
Pumping Marvellous has no bias and no masters so therefore an alternative opinion is provided here
Nick is our Chairman, founder and Trustee of Pumping Marvellous and here is his amazing story but unfortunately not that unusual.
I was diagnosed in January 2010 with Heart Failure. The actual diagnosis was Viral Myocarditis which led to left ventricle impairment and atrial fibrillation. My ejection faction rate after my first Echo cardiogram was 15%, that is low, very low. All this language sounded very alien to me and to be honest I had a roller coaster of a time, as my Consultant said “an evangelical experience”.
It took 4 weeks to diagnose Heart Failure, my legs, feet, toes and abdomen were swollen which I later found out was fluid (medical term is Oedema), I was hallucinating at night seeing green aliens, ask my 8yr old daughter, this was because of the fluid and toxin build up and I was acutely breathless. Basically my Liver, Kidneys and my Heart were shutting down, I couldn’t walk 10 paces without feeling acutely tired – my condition was CHF – Congestive Heart Failure with severe Pulmonary Oedema, my body was failing as the engine room wasn’t working properly.
Just in time I was put into the care of the fantastic Coronary Care Unit who blitzed me with all types of drugs and I lost 35kgs of fluid in 4 days – The Royal Blackburn Hospital Diet, I thought about publishing it. This was achieved through IV Furosemide. After a week on the CCU ward I was transferred to a normal coronary ward to recuperate. I spent 1 week in this ward and was then discharged.
I was then put into the very capable hands of Anglea Graves who is the Clinical Lead for the East Lancashire Specialist Heart Failure Nursing Team. If you have Heart Failure then you must have a Specialist Heart Failure Nurse. I couldn’t have done it without her.
So I had a great consultant Dr John McDonald and Angela Graves my Heart Failure Nurse. Medical support, sorted.
Now what did we need to do. I was referred to rehab which introduced me to exercise that was specifically designed to get me back to as normal a position as possible. Angela and Gemma were fantastic especially in alerting me to the fact my pulse was exceeding 180 beats per minute and the electronic gadgetry was getting confused with my Atrial Fibrillation. This lasted 8 weeks and by the end of it I had an appetite for it although I wasn’t really any good at it, who cares as this is all about me.
I was referred to the Burnley Healthy Lifestyle Team on their BEEP programme which was 12 weeks of hell, well it felt like hell but what a fantastic job Beth and Bill did. I owe these guys a lot and they are real experts in rehabilitation. They guided and coached me through my own exercise programme and by the end of it I felt capable and equipped to go out in the real world and compete with all those gym bunnies. My programme finished in October 2010 and it was one of the most frightening times of my life as I realised all this great support was going to disappear. So it was down to me.
I went back into sinus rhythm out of AF in November 2010 so this was a big milestone but I was still one of those Heart Failure patients that look great from the outside but my inner workings weren’t still correct.
I have always been a determined individual, “No” does not exist in my vocabulary and I was determined to get to grips with my condition right from the start. So because Ineeded to focus on my left ventricle pump rate – that’s what I did.
Knowledge is key, without knowledge you can’t understand your condition. Take an interest and get obsessive with your condition. Understand your limitations but try to develop those limitations. If you want to do it you will. Do not underestimate the power of your determination you will be surprised what you can do. Understand the key levers as to what will effect your condition, my charity has done this for you. They are Nutrition – eat the right stuff and keep focussed around fresh fresh and fresh with low salt intake no more than a level tablespoon of added salt a day (2mg). Reduce your fact intake and cut out any added sugar. Learn to read and interpret food labels, if you buy fresh all the time you won’t have to read food labels will you. Don’t forget supplements, I focused on Vitamin C, Vitamin D, Bovine Colostrum, Acai berries, Krill Oil andvery high quality New Zealand Fish Oils which included ubiquinol. Exercise is really very important but make sure you know your limits and always take advice from a clinician before you start. You will find that exercise releases special endorphins that make you feel great and greater for a couple of days, always try and be active in whatever you do and don’t be put off by Gym Bunnies, these are people who strut their stuff and aren’t looking at you but they expect you to look at them. When I exercise I am in my own little world and I have a structured routine which I don’t deviate from and stretch it a little if I want. I find my music is very important therefore some of my tracks Beat it, Grenade, Welcome to the Pleasuredome (wait for the instrumental on this), Common People, Two Tribes, Atomic, Billie Jean and Beautiful Nightmare you get the drift and rather eclectic. Take your pills; it’s very important to not miss your prescribed tablets but understand what they do and why you are taking them, challenge the clinicians in the right way to get the right answers don’t just take them because you have been prescribed, understand your drugs. Fluid management is very important and you must stick to the guidelines. I was told not to take anymore than 2 litres of fluid in a day so I didn’t. What you have to realise is that lots of everyday things have fluid, chopped tomatoes and apples as examples. I managed this by buying half a litre bottle of bottled water and I never had anymore than 3 which was 1.5 litres and then the other was made up of Green Tea and natural fluid from oranges etc etc. If you take to much fluid on board you will feel worse, guaranteed.
Now my EF is 61% 18 months after my diagnosis and being weened off my drugs.
Anxiety and your Heart
A new study has suggested that levels of anxiety sensitivity are important in choosing medical treatment for patients with heart failure and atrial fibrillation (AF).
Heart and Stroke Foundation researcher and lead author Nancy Frasure-Smith, explained that anxiety sensitivity is the degree to which a person is frightened by bodily sensations and symptoms, particularly those associated with anxiety. ”For most people, sweaty palms and an increasing heart rate are simply unpleasant symptoms that occur in stressful situations, for others these same symptoms are interpreted as a sign of impending doom.
“People with high anxiety sensitivity tend to magnify the potential consequences of their anxiety symptoms, leading to an increase in anxiety and its symptoms in a spiralling increase of fear and worry,” said Frasure-Smith. While anxiety sensitivity is known to predict the occurrence of panic attacks in cardiac and non-cardiac patients, and is associated with greater symptom preoccupation and worse quality of life in patients with AF, it has not been previously studied as a predictor of cardiac outcomes.
These results are based on a sub-study from the Atrial Fibrillation and Congestive Heart Failure Trial (AF-CHF), a randomized trial of rhythm versus rate control treatment strategies whose results were presented at the Canadian Cardiovascular Congress in 2008. Prior to randomization 933 AF-CHF study participants completed a paper and pencil measure of anxiety sensitivity. They were then randomly placed in one of two treatment groups: a ‘rhythm’ group that was treated with anti-arrhythmic medication and cardioversion (an electric shock to convert an abnormal heart rhythm back to normal rhythm); and a ‘rate’ group that received medication to help keep people’s heart rates within a certain range. Participants were followed for an average of 37 months. Results showed that, as in the overall AF-CHF trial, the majority of patients had as good a prognosis with the rate control strategy as with the rhythm control approach.
In contrast, patients with high anxiety sensitivity had significantly better outcomes if they were treated with the more complicated rhythm control strategy.
“Increased emotional responses to AF symptoms in people with high anxiety sensitivity may lead to increased levels of stress hormones making them more vulnerable to fatal arrhythmias and worsening heart failure,” said Frasure-Smith.
The findings were discussed at the Canadian Cardiovascular Congress 2010, co-hosted by the Heart and Stroke Foundation and the Canadian Cardiovascular Society. (ANI)