Peking University Dayi Hu Sept 16, IHF,Beijing, 2005
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Peking University
Dayi Hu
Sept 16, IHF,Beijing, 2005
Atrial Fibrillation in China
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Atrial Fibrillation (AF)
The most common significant heart rhythm The most common significant heart rhythm disturbancedisturbance
Incidence increases with age and the Incidence increases with age and the development of structural heart diseasedevelopment of structural heart disease
Common cause of stroke (10-15% of all strokes)Common cause of stroke (10-15% of all strokes)
Associated with significant cardiovascular Associated with significant cardiovascular morbidity and mortality morbidity and mortality
Tends to recur in at least half the patients being Tends to recur in at least half the patients being treated with antiarrhythmic drug therapytreated with antiarrhythmic drug therapy
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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
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Per
cent
of
subj
ect
die
d in
fol
low
-up
years
Higher Mortality Rate In Patients With AF
Benjamin EJ, Circulation 1998; 946-952
10%
30%
50%
0 1 3 4 652 7 8 9 10
70%
Women, No AF
Men, AF
Women, AF
Men, No AF
men women
Odds Ratio for Death
1.2-1.81.5-2.2
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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)
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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
Generalhealth
Physicalfunction
Social function
Mentalhealth
SF
-36
sco
re
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
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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 ECG0.1%
5.1%3.7%
3.0%2.8%
2.4%
1.5%1.3%
1.3%
0.60%0.28%
Estimate of prevalence of AF vary based on the characteristics of population studied and how AF is ascertained.
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Atrial Fibrillation Demographics by Age
Adapted from Feinberg WM. Arch Intern Med. 1995;155:469-473.
U.S. population
Population withatrial fibrillation
Age, yr
<5 5-9
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. populationx 1000
Population with AFx 1000
30,000
20,000
10,000
0
500
400
300
200
100
0
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Prevalence of AF is increasing in USA N
um
ber
(×
10,0
00)
1984 19940
5.0
10.0
15.0
20.0
25.0
30.0
11.1
27.0
NEJM 1997 337:1360-1369
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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
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% o
f h
osp
ital
izat
ion
7.65%7.90%
8.16%
1999 2000 20016.0%
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%
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The Epidemical Investigation of AF in China
Fourteen Natural Populations, 13 Different Provinces
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Incidence of AF Stratified by Age and Sex in Chinese Population
0
1
2
3
4
5
6
7
8
Age Group, yAge Group, y
Ra
te p
er
100
Ra
te p
er
100
30-3930-39 40-4940-49 50-5950-59 60-6960-69 OverallOverall
Men (n=13358)Men (n=13358)
Women (n=15521)Women (n=15521)
0.30.3 0.20.20.50.5 0.60.6
1.41.4 1.11.1
3.63.62.62.6
7.57.5 7.47.4
70-7970-79 ≥≥8080
0.90.9 0.70.7
Data collected from 13 natural populations from 14 different provinces across China
Hu D, et al. 2004 Chin J Intern Med; in press.
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Difference in Trend between Paroxysmal AF and Persistent AF
0%
1%
2%
3%
4%
5%
6%
7%
8%
30~ 40~ 50~ 60~ 70~ 80~
persi stent AFparoxysmal AF
Hu D, et al. 2004 Chin J Intern Med; in press.
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Similar trends and relatively lower prevalence of AF in China compared with USA, Australia and UK
0
2
4
6
8
10
12
14
30 40 50 60 70 80 90
China
FHS, USA
Australia
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
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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 ECG0.1%
5.1%3.7%
3.0%2.8%
2.4%
1.5%1.3%
1.3%
0.77%0.60%
0.28%
Patients with AF In China 8 million
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Hospitalized Patients with AF in China: Causes and Associated Condition
Idiopathic AF
RVD
CHF
CAD
Advanced age
0 40% 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
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Prevalence of Stroke in Chinese Patients with AF
%
12.95%
24.81%
17.5%
Hu D, 2004 Qi W, 20030
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
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Prevalence of Stroke in Patients with None Valve AF Stratified by Age
years0
5
10
15
20
25
Pre
vale
nce
(%
)
30
>40 40~49
60~ 6950-59 70~79
>80
HU D, et al. Chin J Intern Med, 2003; 42: 157-161
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Framingham Heart Study: Significant Multivariable Risk for developing AF
Prior MI
HTN
DM
VHD
CHF
AGE
0 4 5 6321 7 8 9
Male
Female2.1 (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
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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)
1 2 3 4 5
2.77 (1.25-6.13)
HU D, et al. Chin J Intern Med, 2003; 42: 157-161
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Risk of Stroke: Case-control Study
HU D, et al. Chin J Intern Med, 2003; 42: 157-161
%
Lone AF
PersistenceAF
Control of heart rate
Stroke Control
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
21.218.8
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• Control the ventricular rate
• Restore/maintain sinus rhythm
• Prevent embolic complications
AF Treatment – Possible Objectives
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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.
Str
oke
Inci
denc
e (%
)
95% CI
AF Investigators: Meta-analysis
Warfarin for Stroke Prevention
p < 0.03
p < 0.01
p < 0.02
p > 0.2p < 0.002
p < 0.001
Controls
Warfarin
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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
0 5% 10% 15% 20% 25%
No Therapy
Anticoagulation
Antiplatetet
5.5%
6.7%
24.2%
P<0.001
P<0.001
stroke rate
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No therapy24%
Control ofVenticular Rate
20%Cardioversion
56%
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%
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None3%
Control ofVenticular Rate
83%
Cardioversion14%
Treatment of Chinese Hospitalized patients with persistent AF
Qi W, et al. Chinese J Cardiol, 2003; 31: 913-916
Amiodarone
Digoxin
β-Blocker
CCB
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Prevalence of Antiplatetet and Anticoagulation in Chinese Hospitalized Patients with AF
None35%
Aspirin58%
Warfarin7%
Qi W, et al. Chinese J Cardiol, 2003; 31: 913-916
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Prevalence of Antiplatetet and Anticoagulation in Patients with AF in Chinese Natural Population
None60%
Aspirin38%
Warfarin2%
Hu D, et al. 2004 Chin J Intern Med; in press
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Atrial fibrillation in China:
A Long Way to Go!