Peking University

Dayi Hu

Sept 16, IHF,Beijing, 2005

Atrial Fibrillation in China

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

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

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

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)

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

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.

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

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

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

% 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%

The Epidemical Investigation of AF in China

Fourteen Natural Populations, 13 Different Provinces

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.

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.

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

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

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

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

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

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

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

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

• Control the ventricular rate

• Restore/maintain sinus rhythm

• Prevent embolic complications

AF Treatment – Possible Objectives

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

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

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%

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

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

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

Atrial fibrillation in China:

A Long Way to Go!