Society: Atrial Fibrillation Guidelines Interactive Workshop ACC - PowerPoint PPT Presentation

Canadian Cardiovascular Society: Atrial Fibrillation Guidelines Interactive Workshop ACC Rockies 2012 John A Cairns, MD, FRCPC, FACC University of British Columbia, Canada jacairns@medd.med.ubc.ca

Disclosures: John A Cairns DSMBs • Chair, AVERROES (apixaban), Chair, SHIELD-2 (azimilide) • Member, ACTIVE Trials (aspirin, clopidogrel, warfarin), PALLAS (dronedarone) Advisory Boards • Boehringer Ingelheim Canada (Since Nov 2010) • St Jude Medical (Since January 2012) Research Grants • Medtronic, Astra Zenica

CCS AF Guidelines 2010 Primary Panel • Anne Gillis (co chair) • Brent Mitchell • Allan Skanes (co chair) • Stanley Nattel • John Cairns • Pierre Pagé • Stuart Connolly • Ratika Parkash • Jafna Cox • P. Timothy Pollak • Paul Dorian • Michael Stephenson • Jeff Healey • Ian Stiell • Laurent Macle • Mario Talajic • Sean McMurtry • Teresa Tsang • Atul Verma Atrial Fibrillation Guidelines

GRADE Approach Clear separation of 2 issues: 1. Four Categories of Quality of Evidence:  High, Moderate, Low or Very Low 2. Strength of Recommendations : 2 Grades  Strong or Conditional (weak)  Quality of evidence only one factor Atrial Fibrillation Guidelines

CCS AF Guidelines Process  Guidelines Development : 2009-10  CCS Presentations  CJC Publication: Jan/Feb 2011  CCS website – slide set - pocket guide - webinairs  CME events  Update Process: 2011-12  CJC Publication: Mar/Apr 2012 Atrial Fibrillation Guidelines

CCS AF Guidelines 2012 Update Primary Panel Jeff Healey (co chair) Allan Skanes (co chair) Stroke Prevention Rate and Rhythm • John Cairns (Chair) • Atul Verma (Chair) • Stuart Connolly • Brent Mitchell • Sean McMurtry • Stanley Nattel • Mario Talajic • Paul Dorian • Carl van Walraven • Anne Gillis • Gord Gubitz • Ratika Parkash • P. Timothy Pollak • Ian Stiell • Teresa Tsang • Jafna Cox Atrial Fibrillation Guidelines

CCS AF Guidelines 2012 Update What’s New? • New oral anticoagulants • Predicting risk of stroke • Use of new agents in CAD • Anticoagulation and Chronic Kidney Disease • New evidence about Dronederone Atrial Fibrillation Guidelines

Atrial Fibrillation Guidelines

CCS AF Guidelines 2012 Update What’s New in Stroke Prevention? • New oral anticoagulants • Predicting risk of stroke • Use of new agents in CAD • Anticoagulation and Chronic Kidney Disease Atrial Fibrillation Guidelines

RELY Dabigatran for stroke prevention in atrial fibrillation Non-valvular atrial fibrillation at moderate to high risk of stroke or systemic embolism (at least one high risk factor) R Warfarin Dabigatran Etexilate Dabigatran Etexilate 1 mg, 3mg, 5 mg 150 mg b.i.d. 110 mg b.i.d. (INR 2.0-3.0) N=6000 N=6000 N=6000 • Primary objective: Noninferiority to warfarin • Minimum 1 year follow-up, maximum of 3 years and mean of 2 years of follow-up. • Primary end point: Stroke + systemic embolism

Connolly SJ, et al. NEJM 2009;361 RR = 0.91, P<0.001, non-inf RR = 0.66, P<0.001 sup mo. RE-LY Trial. Stroke or Systemic Embolism

Connolly SJ, et al. NEJM 2009;361 RR = 0.91, P<0.001, non-inf RR = 0.66, P<0.001 sup mo. RE-LY Trial. Stroke or Systemic Embolism

Major bleeding rates RR 0.80 (95% CI: 0.69 – 0.93) p=0.003 (sup) RR 0.93 (95% CI: 0.81 – 1.07) 3.50 p=0.31 (sup) RRR 3.36 20% 3.00 3.11 2.71 2.50 % per year 2.00 1.50 1.00 0.50 0.00 D110 mg BID D150 mg BID Warfarin 375 / 6,076 397 / 6,022 322 / 6,015 Connolly SJ., et al. NEJM published online on Aug 30th 2009. Dabigatran etexilate is in clinical development and not licensed for DOI 10.1056/NEJMoa0905561 clinical use in stroke prevention for patients with atrial fibrillation

Risk Factors • CHF At least 2 • Hypertension required • Age  75 Atrial Fibrillation • Diabetes OR • Stroke, TIA or Systemic embolus Rivaroxaban Randomize Warfarin Double blind / Double Dummy (n ~ 14,000) 20 mg daily INR target - 2.5 15 mg for Cr Cl 30-49 (2.0-3.0 inclusive) Monthly Monitoring and adherence to standard of care guidelines Primary Endpoint: Stroke or non-CNS Systemic Embolism Statistics : non-inferiority, >95% power, 2.3% warfarin event rate 17

Primary Efficacy Outcome Stroke and non-CNS Embolism 6 Rivaroxaban Warfarin Cumulative event rate (%) Warfarin 5 Event 1.71 2.16 Rate 4 Rivaroxaban 3 HR (95% CI): 0.79 (0.66, 0.96) 2 P-value Non-Inferiority: <0.001 1 0 0 120 240 360 480 600 720 840 960 Days from Randomization No. at risk: Rivaroxaban 6958 6211 5786 5468 4406 3407 2472 1496 634 Warfarin 7004 6327 5911 5542 4461 3478 2539 1538 655 Event Rates are per 100 patient-years Based on Protocol Compliant on Treatment Population

Primary Safety Outcomes Rivaroxaban Warfarin HR P- Event Rate Event Rate (95% CI) value Major and non-major 14.91 14.52 1.03 (0.96, 1.11) 0.442 Clinically Relevant Major 3.60 3.45 1.04 (0.90, 1.20) 0.576 Non-major Clinically 11.80 11.37 1.04 (0.96, 1.13) 0.345 Relevant Event Rates are per 100 patient-years Based on Safety on Treatment Population

Atrial Fibrillation with At Least One Additional Risk Factor for Stroke  Age ≥ 75 years Randomize  Prior stroke, TIA or SE Double blind  CHF or LVEF ≤ 40% (n = 15,000) ARISTOTLE  Diabetes mellitus  Hypertension Apixaban placebo twice daily Apixaban 5 mg oral twice daily + + Warfarin (target INR 2-3) Warfarin placebo Warfarin/warfarin placebo adjusted by INR/sham INR based on encrypted point-of-care testing device Primary outcome: stroke and systemic embolism Other outcomes: Death, MI, bleeding Stratified by warfarin-naïve status 448 events over anticipated 2 year median follow-up; >90% power to show non-inferiority (apixaban vs warfarin upper bound of 95% CI <1.38)

Primary Outcome Stroke (ischemic or hemorrhagic) or systemic embolism 21% RRR Apixaban 212 patients, 1.27% per year Warfarin 265 patients, 1.60% per year HR 0.79 (95% CI, 0.66 – 0.95); P (superiority)=0.011 No. at Risk Apixaban 9120 8726 8440 6051 3464 1754 Warfarin 9081 8620 8301 5972 3405 1768

Major Bleeding ISTH definition 31% RRR Apixaban 327 patients, 2.13% per year Warfarin 462 patients, 3.09% per year HR 0.69 (95% CI, 0.60 – 0.80); P<0.001 No. at Risk Apixaban 9088 8103 7564 5365 3048 1515 Warfarin 9052 7910 7335 5196 2956 1491

CHADS 2 CHA 2 DS 2 -VASc Risk Factor Score Risk Factor Score Congestive Heart Failure 1 Congestive Heart Failure 1 Hypertension 1 Hypertension 1 Age ≥ 75 Age ≥ 75 1 2 Diabetes Mellitus 1 Diabetes Mellitus 1 Stroke/TIA/Thrombo- 2 Stroke/TIA/Thrombo- 2 embolism embolism Vascular Disease 1 Age 65-74 1 Female 1 Maximum Score 6 Maximum Score 9

Validation of CHA 2 DS 2 VASc Olesen et al. BMJ 2011;342:d124 HRs for Hospital Admission or Death due to Thromboembolism by 5 years’ Follow -up HR P-value event % • CHA 2 DS 2 VASc score = 0 1.0 0.69 CHA 2 DS 2 VASc score = 1 Heart failure 3.39 <0.001 Hypertension 2.32 <0.0001 Diabetes 3.31 <0.0001 Vascular Disease 2.04 0.002 1.40 Age 65-74 3.07 <0.0001 2.13 Female sex 1.25 <0.10 0.86

Validation of CHA 2 DS 2 VASc Olesen et al. BMJ 2011;342:d124 HRs for Hospital Admission or Death due to Thromboembolism by 5 years’ Follow -up HR P-value event % • CHA 2 DS 2 VASc score = 0 1.0 0.69 CHA 2 DS 2 VASc score = 1 Heart failure 3.39 <0.001 Hypertension 2.32 <0.0001 Diabetes 3.31 <0.0001 Vascular Disease 2.04 0.002 1.40 Age 65-74 3.07 <0.0001 2.13 Female sex 1.25 <0.10 0.86 • CHA 2 DS 2 VASc score = 2 • Vasc dis + Female 2.81 <0.008 1.95

Atrial Fibrillation Guidelines

RE-LY Yearly Event Rate (%) Dabi 110 Dabi 150 Warf Dabi vs warf MI 0.82 0.81 0.64 HR 1.28, P=0.07 MI, UA, Card arrest or card death 3.16 3.33 3.41 HR 0.96, P=0.50 Stroke, SEE other card isch events 4.76 4.47 5.10 HR 0.90, P=0.05 Net clin benefit 7.34 7.11 7.91 HR 0.91, P=0.02 Submitted to Circulation - Confidential

Dabigatran and MI in RE-LY (& other trials) Mortality OR 0.89; 95% CI: 0.80-0.99 Uchino K, et al. Arch Intern Med 2012

Dabigatran and MI in RE-LY 0.25 Dabigatran 110 Dabigatran 150 Warfarin 0.20 Cumulative Hazard Rates 0.15 Net clinical benefit 0.10 0.05 Stroke/SEE/MI/UA/PCI/CABG/ Cardiac arrest/Cardiac death MI 0.0 0 0.5 1.0 1.5 2.0 2.5 Years of Follow-up Hohnloser S, et al. Circulation 2012 (in press)

Phase II and III Trials in ACS DAPT + new OAC vs DAPT REDEEM, APPRAISE, ATLAS-1 : Similar rates of ischemic outcomes ATLAS-2: Significant reduction of composite outcome of CV death, MI or stroke (AHA)