1. Stroke and AF in the Elderly Dr Ali Ali Consultant Geriatrician and Stroke Physician Sheffield Teaching Hospitals

2. Objectives Magnitude of the problem Implications of AF related stroke Evidence for anti-platelets and oral anticoagulants (OAC) in the elderly Benefit vs harm and risk stratification tools

3. Atrial fibrillation (AF) Commonest sustained cardiac arrythmia. Characterised by disordered electrical activity of the atria resulting in an irregularly-irregular pulse. Diagnosed clinically (pulse check), confirmed electrocardiographically.

4. Ageing population and AF Prevalence of AF related to age: –All ages – 1-2% –< 55 yrs – 0.1% –65-74yrs – 6% –75-84 yrs – 12% –≥ 85 yrs – 16% –> 90 years – 20% Sheffield: 2010 2035 Prevalence 1.6% 2.8% Total9,000 16,000 Avg practice 80 140 (5000) ONS Fitzmaurice 2007

5. Implications of AF Symptomatic: –Palpitations- Chest pain –Dyspnoea- Exercise intolerance Tachycardiomyopathy Stroke & systemic embolism

6. AF related stroke Overall 5 x increased risk of stroke. Accounts for 15-20% all strokes. This attributable risk increases with age: Marini 2005

7. Stroke severity in AF AF related strokes are more severe than non-AF related strokes: SRAF NIHSS39 Oxford class: - LACS (%) - TACS 40.4 11.6 12.6 40.9 Discharge MRS  2 57.023.2 Local unpublished data

8. AF strokes 3 x more likely to be classed severe (NIHSS,SSS) Reduced conscious level 2 x as likely to remain severely functionally impaired during inpatient stay Stroke severity in AF Steger 2005, Kimura 2005, Thygesen 2009 Kimura 2005

9. Stroke outcomes in AF Broderick 1992, Sandercock 1992, Lin 1996, Lamassa 2001, Kimura 2005, Ghatnekar 2008, Thygesen 2009, Hannon 2010, Saposnik 2013

10. Stroke outcomes in AF Lin 1996

11. AF related stroke Human cost Morbidity & mortality Economic cost Increased length inpatient stay 1.5 – 2 x inpatient costs Half patients require discharge to institutional care (versus 25% non-AF stroke)

12. AF versus non-AF stroke Fibrin rich clotPlatelet rich clot

13. Warfarin vs aspirin for stroke prevention in AF Meta-analysis 11 RCT’s – 2007: Warfarin reduces stroke risk ~ 64% Aspirin reduces stroke risk ~ 19% –Similar to risk reduction in stroke when given for general vascular disease 39% risk reduction - warfarin vs aspirin Hart 2007

14. Warfarin vs aspirin in the elderly AFASAK-1 SPAF BAATAFAverage age 69 yrs CAFA SPINAF EAFT Under-representation in older RCT’s? Benefit vs risk in the elderly? Aguilar 2005

15. Warfarin vs aspirin in the elderly BAFTA (2007): –973 patients  75 years (avg 81.5yrs) –Warfarin (INR 2-3) vs aspirin (75mg od) –Primary end-point – fatal or disabling stroke, ICH, or systemic embolism: Warfarin 1.8% vs aspirin 3.8% RR reduction 52% –ICH: warfarin 0.7% vs aspirin 0.5% - NS Mant 2007

16. Protective effect of warfarin persisted with increasing age Protective effect of aspirin diminished with age – no better than placebo after the age of 78yrs. Warfarin vs aspirin in the elderly Van Walraven 2009

17. Bleeding risk in the elderly Rates major bleeding ~ 1.5 – 2 x for those > 80 yrs compared to < 80 yrs –Irrespective of anti-thrombotic used –Depends on study methodology (inception cohort > cohort > RCT) –Annual risk with warfarin ranges 2% - 13% Particularly concerned about ICH – warfarin 2 x aspirin –Absolute numbers low 0.5% - 1% Effective education and INR control is possible in the very old (> 80 yrs) and results in excellent risk profiles Hylek 2007, Pisters 2011, Poli 2011