2. Which tool do you most typically use to evaluate stroke risk for patients with a fib? 1. CHADS2 score 2. CHADS2-VASc 3. Other 10

3.  Patient › 56 y/o F › PMH: A fib, Diastolic HF, HTN, COPD, GERD, MDD › Medications  Coumadin 2mg QD  Lasix 60mg BID  K Cl 20mEq QD  Diltiazem 120mg BID  Spiriva 18mcg QD  Flovent 44mcg/act 1 inhalation BID  Albuterol Nebulizer 0.083% Q4-6H PRN SOB  TUMS 500mg TID PRN  Lexapro 20mg QD  APAP 650mg Q6H PRN  Colace 100mg BID  Bisacodyl 10mg Supp QD PRN

4.  C.S. began obsessing over her INR value which was (unstable in her perspective), ranging from 1.9 to 3.1 over the past 5 months…  Transitioned to Xarelto › NH called reported patient refused Xarelto for past 3 days…  Concerns w/ SE, especially bleeding

5. When calculating stroke risk, does diastolic HF carry as much risk as systolic HF? 1. Yes 2. No 3. Unsure 10

6.  PMH: A fib, CHF, HTN, COPD, GERD, MDD  What is C.S. CHADS2 Score?  What is her CHADS2VASc Score?  Any other risk stratification systems you use?

7.  Retrospective analysis  Centre Hospitalier Regional et Universitaire in Tours (France) – all patients diagnosed w/ NVAF between 2000 and 2010  Exclusion criteria › No hx chronic HF or echo LV function N/A › Valvular dysfunction  Stratified into 4 categories – 1276 patients included  Severe LV impairment w/ EF <35%  Moderate LV impairment w/ EF 35-40%  Mild LV impairment w/ EF 41-49%  Normal LV Function w/ EF ≥ 50%* *HFPEF defined as clinical HF w/ EF ≥ 50%

8.  Results › Comparing HFPEF & HFREF  no statistical differences in stroke, stroke/TE, all-cause death, or bleeding

9. Which risk factor is the strongest, most consistent independent risk factor for stroke? 1. CHF 2. HTN 3. Age > 75 years 4. Diabetes 5. Prior Stroke/TIA 10

10.  Methods › 7 studies (6 independent cohorts) › Systematic review using multivariate regression analysis to identify independent risk factors for stroke in patients with a fib

11.  Results › Prior Stroke/TIA (RR 2.5, 95% CI 1.8-3.5) › Increasing Age (RR 1.5 per decade, 95% CI 1.3-1.7) › Hx HTN (RR 2.0, 95% CI 1.6-2.5) › Diabetes Mellitus (RR1.7, 95% CI 1.4-2.0) › HF (RR 1.4, 95% CI 0.8-2.3)  Observed absolute stroke rates for non- anticoagulated patients w/ single independent risk factors › Prior Stroke/TIA: 6-9% per year › Age >75 years: 1.5-3% › Hx HTN: 1.5-3% per year › Diabetes: 2-3.5% per year

12. What would you recommend for C.S. based solely on her CHADS ₂ Score of 2 & CHADS₂VASc Score of 3? 1. No antithrombotic therapy 2. ASA 75-325mg QD 3. Oral anticoagulant 10

14. What would you recommend for C.S. based on her CHADS ₂ Score of 2 & CHADS₂VASc Score of 3 and her history? 1. No antithrombotic therapy 2. ASA 75-325mg QD 3. Oral anticoagulant 10

16.  Evidence suggests diastolic heart failure is as much a risk factor for stroke as systolic heart failure  Strongest Independent predictors of stroke are Hx Stroke/TIA Increasing age, Hx HTN & Diabetes

17. THANK- YOU!

18.  Abraham, JoEllyn & Connolly, Stuart. Atrial fibrillation in heart failure: stroke risk stratification and anticoagulation. Heart Fail Rev 2014, 19:305-313. Springer Science + Business Media, New York. 21 Jan 2014.  Banerjee, et al. Ejection fraction and outcomes in patients with atrial fibrillation and heart failure: the Loire Valley Atrial Fibrillation Project. European Journal of Heart Failure 2012, 14, 295-301. 24 October 2011.  UpToDate: http://www-uptodate- com.proxy.lib.uiowa.edu/contents/image?imageKey=CARD/61615&topicKe y=CARD%2F1031&source=outline_link&search=atrial+fibrillation%3A+anticao gulation+to+prevent+thromboembolism&selectedTitle=2%7E150&utdPopup= tru. Accessed 19 October 2015.http://www-uptodate- com.proxy.lib.uiowa.edu/contents/image?imageKey=CARD/61615&topicKe y=CARD%2F1031&source=outline_link&search=atrial+fibrillation%3A+anticao gulation+to+prevent+thromboembolism&selectedTitle=2%7E150&utdPopup= tru