1. Peking University Dayi Hu Sept 16, IHF,Beijing, 2005 Atrial Fibrillation in China

2. Atrial Fibrillation (AF) The most common significant heart rhythm disturbance Incidence increases with age and the development of structural heart disease Common cause of stroke (10-15% of all strokes) Associated with significant cardiovascular morbidity and mortality Tends to recur in at least half the patients being treated with antiarrhythmic drug therapy

3. 34% Atrial Fibrillation 6% PSVT 6% PVCs 4% Atrial Flutter 9% SSS 8% Conduction Disease 3% SCD 10% VT AF accounts for 1/3 of all pts discharges with arrhythmia as principal diagnosis 2%VF Baily D. J Am Coll Cardiol. 1992; 19: 41A. 18% Unspecified

4. Percent of subject died in follow-up years Higher Mortality Rate In Patients With AF Benjamin EJ, Circulation 1998; 946-952 10% 30% 50% 0 13465278910 70% Women, No AF Men, AF Women, AF Men, No AF menwomen Odds Ratio for Death 1.2-1.8 1.5-2.2

5. 0 10 20 30 Wolf et al. Stroke 1991;22:983-988. 50–59 60–69 70–79 80–89 The Framingham Study: Attributable Risk of Stroke % AF prevalence Strokes attributable to AF Age Range (years)

6. Dorian P et al. J Am Coll Cardiol. 2000; 36: 1303-1309. Quality of life: AF vs. CAD vs. healthy controls Higher scores = better QQL 0 2 4 6 8 General health Physical function Social function Mental health SF-36 score 10 * ** *† † AF CAD Controls * P<0.05, patients with AF compared to healthy controls † P<0.05, patients with AF compared to those with CAD

7. Ryder KM, et al. Am J Cardiol 1999; 84: 131R-138R. Prevalence of AF in different countries 5.5% 5.4% ≥ 50 yrs, USA (CHS), single ECG ≥ 65 yrs, UK, single ECG ≥ 60 yrs, Netherlands, single ECG & medical record ≥ 50 yrs, UK, single ECG ≥ 55 yrs, Netherlands, single ECG ≥ 35 yrs, USA, medical record ≥ 50 yrs, UK, single ECG Review results ≥ 60 yrs, Australia, triennial survey ≥ 40 yrs, Japan, single ECG ≥ 60 yrs, Hong Kong, single ECG ≥ 35 yrs, Denmark, single ECG 25 - 64 yrs, west German, single ECG ≥ 15 yrs, India, single ECG 0.1% 5.1% 3.7% 3.0% 2.8% 2.4% 1.5% 1.3% 0.60% 0.28% Estimate of prevalence of AF vary based on the characteristics of population studied and how AF is ascertained.

8. Atrial Fibrillation Demographics by Age Adapted from Feinberg WM. Arch Intern Med. 1995;155:469-473. U.S. population Population with atrial fibrillation Age, yr <55- 9 10- 14 15- 19 20- 24 25- 29 30- 34 35- 39 40- 44 45- 49 50- 54 55- 59 60- 64 65- 69 70- 74 75- 79 80- 84 85- 89 90- 94 >95 U.S. population x 1000 Population with AF x 1000 30,000 20,000 10,000 0 500 400 300 200 100 0

9. Prevalence of AF is increasing in USA Number (×10,000) 19841994 0 5.0 10.0 15.0 20.0 25.0 30.0 11.1 27.0 NEJM 1997 337:1360-1369

10. Cardiovascular Medicine at the Turn of the Millennium: Triumphs, Concerns, and Opportunities Two new epidemics of cardiovascular disease are emerging: heart failure and atrial fibrillation. Eugene Braunwald NEJM 1997 337:1360-1369

12. % of hospitalization 7.65% 7.90% 8.16% 199920002001 6.0% 6.5% 7.0% 7.5% 8.0% 9.0% Qi W, et al. Chinese J Cardiol, 2003 ； 31 ： 913-916 Percent of Hospitalization in Patients with AF Is Increasing in China Average 7.90%

13. The Epidemical Investigation of AF in China Fourteen Natural Populations, 13 Different Provinces

14. Incidence of AF Stratified by Age and Sex in Chinese Population Age Group, y Rate per 100 30-3940-4950-5960-69Overall Men (n=13358) Women (n=15521) 0.30.2 0.50.6 1.41.1 3.6 2.6 7.57.4 70-79≥80 0.9 0.7 Data collected from 13 natural populations from 14 different provinces across China Hu D, et al. 2004 Chin J Intern Med; in press.

15. Difference in Trend between Paroxysmal AF and Persistent AF Hu D, et al. 2004 Chin J Intern Med; in press.

16. Similar trends and relatively lower prevalence of AF in China compared with USA, Australia and UK FHS: the Framingham study. Wolf PA et al. Sroke 1991; 22: 983-988 Australia: Lake FR, et al. Aust NZ Med 1989; 19: 321-326 UK: Hill JD et al. J R Coll Gen Pract 1987; 37: 172-173 % years

17. Prevalence of AF in China and other countries 5.5% 5.4% ≥ 50 yrs, USA (CHS), single ECG ≥ 65 yrs, UK, single ECG ≥ 60 yrs, Netherlands, single ECG & medical record ≥ 50 yrs, UK, single ECG ≥ 55 yrs, Netherlands, single ECG ≥ 35 yrs, USA, medical record ≥ 50 yrs, UK, single ECG Review results ≥ 60 yrs, Australia, triennial survey ≥ 40 yrs, Japan, single ECG ≥ 60 yrs, Hong Kong, single ECG ≥ 35 yrs, main land, China, single ECG ≥ 35 yrs, Denmark, single ECG 25 - 64 yrs, west German, single ECG ≥ 15 yrs, India, single ECG 0.1% 5.1% 3.7% 3.0% 2.8% 2.4% 1.5% 1.3% 0.77% 0.60% 0.28% Patients with AF In China 8 million

18. Hospitalized Patients with AF in China: Causes and Associated Condition Idiopathic AF RVD CHF CAD Advanced age 040%50%60%30%20%10% 58.1% 40.3% Hypertension caidiomyopathy 34.8% 33.1% 23.9% 7.4% 5.4% 4.1% Diabetes CAD: coronary artery disease; CHF: congestive heart failure; RVD: rheumatic valve disease Chinese J Cardiol, 2003 ； 31 ： 913-916

19. Prevalence of Stroke in Chinese Patients with AF % 12.95% 24.81% 17.5% Hu D, 2004Qi W, 2003 0 5% 10% 15% 20% 25% Hu D, 2004 Hu D, et al. 2004 Chin J Intern Med; in press. Random sample of population Qi W, et al. 2003 Chin J Cardiol; 31: 913-916. Case-control study. Hospitalized patients Hu D, et al. 2003 Chin J Intern Med; 42: 157-161. Case-control study. Hospitalized patients

20. Prevalence of Stroke in Patients with None Valve AF Stratified by Age years 0 5 10 15 20 25 Prevalence (%) 30 >40 40 ～ 4960 ～ 69 50-59 70 ～ 79 >80 HU D, et al. Chin J Intern Med, 2003; 42: 157-161

21. Framingham Heart Study: Significant Multivariable Risk for developing AF Prior MI HTN DM VHD CHF AGE 0456321 789 Male Female 2.1 (1.8-2.5) 2.2 (1.9-2.6) 4.5 (3.1-6.6) 4.2 (4.2-8.4) 1.8 (1.2-2.5) 3.4 (2.5-4.5) 1.4 (1.0-2.0) 1.5 (1.2-2.0) 1.4 (1.1-1.8) 1.4 (1.0-2.0) 1.6 (1.1-2.2) Benjamin EJ, et al. JAMA, 1994; 271: 840-844

22. Risk Factors for Stroke in Chinese with Non Vascular AF: A Case-control Study AGE >76 yrs Hypertension Diabetes LA thrombi SBP 1.76 (1.08-2.89) 1.52 (1.28-1.80) 1.39 (1.11-1.76) 1.71 (1.21-2.28) 12345 2.77 (1.25-6.13) HU D, et al. Chin J Intern Med, 2003; 42: 157-161

23. Risk of Stroke: Case-control Study HU D, et al. Chin J Intern Med, 2003; 42: 157-161 % Lone AF Persistence AF Control of heart rate StrokeControl 5.6 62.4 75.2 2.3 94.4 97.7 P<0.001 0 25 66.9 37.6 Paroxymal AF Conversion 50 75 24.8 51.9 P=0.21 100 None valve AF P=0.009 21.2 18.8

24. Control the ventricular rate Restore/maintain sinus rhythm Prevent embolic complications AF Treatment – Possible Objectives

25. 0 2 4 6 8 AFASAK 58% 7– 81 SPAF 67% 27– 85 BAATAF 86% 51– 96 CAFA 42% - 68– 80 SPINAF 79% 52– 90 TOTAL 68% 50–79 Risk reduction AF Investigators. Arch Intern Med 1994;154:1449-1457. Atwood et al. Herz 1993;18:27-38. Stroke Incidence (%) 95% CI AF Investigators: Meta-analysis Warfarin for Stroke Prevention p < 0.03 p < 0.01 p < 0.02 p > 0.2 p < 0.002 p < 0.001 Controls Warfarin

26. Antiplatetet and Anticoagulation showed Significant Lower Stroke in Chinese Hospitalized Patients with AF Number of Strokes Prevented Qi W, et al. Chinese J Cardiol, 2003 ； 31 ： 913-916 05%10%15%20%25% No Therapy Anticoagulation Antiplatetet 5.5% 6.7% 24.2% P<0.001 stroke rate

27. Treatment of Chinese Hospitalized patients with paroxymal AF Qi W, et al. Chinese J Cardiol, 2003 ； 31 ： 913-916 Amiodarone 31.0% Cedilanid 29.6% β-Blocker 18.3% Propafenone 14.3%

28. Treatment of Chinese Hospitalized patients with persistent AF Qi W, et al. Chinese J Cardiol, 2003 ； 31 ： 913-916 Amiodarone Digoxin β-Blocker CCB

29. Prevalence of Antiplatetet and Anticoagulation in Chinese Hospitalized Patients with AF Qi W, et al. Chinese J Cardiol, 2003 ； 31 ： 913-916

30. Prevalence of Antiplatetet and Anticoagulation in Patients with AF in Chinese Natural Population Hu D, et al. 2004 Chin J Intern Med; in press

31. Atrial fibrillation in China: A Long Way to Go!