Atrial Fibrilation

1. In your experience, which of the following is the most important patient-related barrier to the optimal management of AF? (select only one) Adherence to medications Side effects from medications Medications too expensive Too many pills to take in 1 day Do not like getting frequent blood tests Limited access to care Your Colleagues Responded: 37% 20% 4% 5% 25% 6%

2. In your experience, which of the following is the most important physician-related barrier to the optimal management of AF? (select only one) Medications have low efficacy Medication side effects Studies do not support the use of potentially toxic agents Do not know most recent studies Reimbursement is too low for checking event recorders and follow-up International Normalized Ratio (INR) levels Antiarrhythmic medications are too confusing Your Colleagues Responded: 13% 39% 4% 17% 10% 13%

5. Case #1: A 72-year-old woman, with a history of hypertension that is well controlled with amlodipine, presents to her family physician with a history of symptomatic intermittent palpitations. Her family physician ordered 24-hour Holter monitoring -- during the period of recording, the patient did not report palpitations and the monitor only revealed occasional premature atrial contractions. Blood test results, including those of blood glucose and thyroid function, were normal. Over the course of the next several months, the palpitations persisted. The patient was referred to a cardiologist by her family physician. Physical examination is normal. An event recorder documented several episodes of AF, lasting between several minutes and several hours. Echocardiography was performed, results of which showed normal left ventricular ejection fraction, no valvular abnormalities, and normal wall thickness (no hypertrophy). The patient has no contraindication to anticoagulant therapy and has no history of stroke or transient ischemic

attack (TIA). Which stroke risk classification scheme are you most familiar with: (select only one) Framingham Heart Study CHADS2 CHADS1 Stroke Prevention in Atrial Fibrillation (SPAF) American Heart Association (AHA) Your Colleagues Responded: 17% 39% 4% 15% 22%

6. The CHADS2 stroke risk classification scheme assigns a score based on which of the following? (select only one) 1 point for history of TIA or stroke, age older than 75, history of hypertension, diabetes mellitus (DM), or recent heart failure 2 points for history of TIA or stroke and 1 point for age older than 50, woman, left ventricular hypertrophy, left atrial dilatation 2 points for history of TIA or stroke and 1 point for age older than 75, history of hypertension, DM, or recent heart failure 1 point for age older than 70, hypertension, hypertrophy, atrial dilatation, and mitral stenosis

Your Colleagues Responded: 15% 19% 59% 5%

The CHADS2 score is a clinical prediction rule for estimating the risk for stroke in patients with nonrheumatic AF. The scoring system is: Condition C Congestive heart failure H Hypertension (or treated hypertension) A Age > 75 years D Diabetes S2 Prior Stroke or TIA Points 1 1 1 1 2

7. The patient's CHADS2 stroke risk would be classified as? (select only one) Low Moderate Your Colleagues Responded: 44% 41%

High Indeterminate

11% 2%

8. Which antiplatelet-anticoagulant therapy would you recommend for this patient? (select only one) No therapy Aspirin Clopidogrel + aspirin Prasugrel

Your Colleagues Responded: 5% 61% 30% 2%

This patient has a moderate risk for stroke. The following treatment strategies were recommended: Score 0 1 Risk Low Moderate Aspirin Aspirin daily or increase INR to 2.0-3.0, depending on factors such as patient preference Increase INR to 2.0-3.0, unless contraindicated (eg, history of falls, clinically significant gastrointestinal bleeding, inability to obtain regular INR screening) Anticoagulation Therapy Considerations

2 or Moderate greater or High

Warfarin

9. In patients with hypertension and AF, which antihypertensive agents may have beneficial effects in reducing the incidence of AF? (select only one) Calcium-channel blockers Angiotensin-converting enzyme (ACE) inhibitors Diuretics Antihypertensive drugs have no beneficial effects

Your Colleagues Responded: 48% 34% 2% 14%

A recent analysis of a subgroup of patients enrolled in the Studies of Left Ventricular Dysfunction (SOLVD) trial confirmed the antifibrillatory role of ACE inhibitors.

10. Case #1 continued: This patient was started on warfarin (INR 2.0- 3.0). One year later, the patient returned to her cardiologist with palpitations, which started 1 week previously. Electrocardiography (ECG) documented AF. Electrical cardioversion was successful.

Administration of an antiarrhythmic agent to maintain sinus rhythm is being considered. Administration of dronedarone, compared to placebo, would be expected to: (select only one) Reduce hospitalizations, cardiovascular mortality, and recurrence of AF Reduce AF but have no effect on hospitalizations Have equivalent efficacy to prevent AF but with fewer side effects Reduce total mortality and AF recurrence Your Colleagues Responded: 42% 28% 14% 15%

11. Case #2: A 54-year-old man with a history of hypertension and diabetes has a 6-month history of intermittent palpitations and AF. His echocardiogram was normal. Results of a perfusion stress test were normal. He underwent anticoagulation therapy with warfarin and then underwent electrical cardioversion, but the AF recurred within 2 months. He is very symptomatic despite good rate control with metoprolol. He now returns to your office for advice regarding optimal management. On the basis of this patient's CHADS2 score and recent studies, what would you recommend for long-term anticoagulation? (select only one) Aspirin Aspirin + clopidogrel Warfarin Either aspirin + clopidogrel or warfarin

Your Colleagues Responded: 9% 11% 64% 15%

This patient has a moderate risk for stroke. The following treatment strategies were recommended:

Score 0 1

Risk Low Moderate

Anticoagulation Therapy

Considerations

Aspirin

Aspirin daily or increase INR to 2.0-3.0, depending on factors such as patient preference

2 or Moderate greater or High

Warfarin

Increase INR to 2.0-3.0, unless contraindicated (eg, history of falls, clinically significant gastrointestinal bleeding, inability to obtain regular INR screening)

12. On the basis of recent studies such as AFFIRM (Atrial Fibrillation Follow-up Investigation of Rhythm Management) or RACE (Rate Control vs Electrical Cardioversion for persistent atrial fibrillation), which strategy do you recommend for reducing mortality or stroke risk? (select only one) Rate control Rhythm control Neither rate nor rhythm control is superior Your Colleagues Responded: 36% 29% 34%

13. On the basis of the 2006 American College of Cardiology (ACC)/AHA/European Society of Cardiology (ESC) guidelines for antiarrhythmic drugs, which antiarrhythmic agent would be most appropriate for maintenance of sinus rhythm in this patient? (select only one) Type IA agents, such as quinine or procainamide Type III agents, such as dofetilide or sotalol Type IC agents, such as flecainide Amiodarone Your Colleagues Responded: 6% 22% 16% 54%

The 2006 ACC/AHA/ESC guidelines algorithm is:

14. On the basis of the recently reported studies EURIDIS, ADONIS, and ATHENA would dronedarone (if US Food and Drug Administration approved) be an appropriate therapeutic option to maintain sinus rhythm in this patient? (select only one) Yes No The studies do not apply to this patient I am not aware of these studies Your Colleagues Responded: 41% 5% 5% 47%

Introduction

One of the goals of continuing healthcare education is to acquire and retain new knowledge that will ultimately affect clinical practice and patient outcomes. The following survey is a baseline assessment instrument that measures gaps in guideline adherence and competencies associated with the learning objectives in a series of activities. The survey is available for CME credit. These activities are developed and subsequently published on Medscape as part of the overall Advances in Atrial Fibrillation (AF) curriculum. The initial survey data represent the baseline, with each activity's post-test showing educational effect. The survey will test your knowledge of AF screening and initial treatment, and specifically will assess your use of evidence-based treatment strategies and measure any performance improvement in future clinical practice. Data from this baseline survey activity will help facilitate recommendations for future programs that will best meet the educational and clinical performance gaps identified. We encourage you to complete this survey activity and earn CME credit.

Questions answered incorrectly will be highlighted. 1. In your experience, which of the following is the most important patient-related barrier to the optimal management of AF? (select only one) Adherence to medications Side effects from medications Medications too expensive Too many pills to take in 1 day Do not like getting frequent blood tests Limited access to care 2. In your experience, which of the following is the most important physician-related barrier to the optimal management of AF? (select only one) Medications have low efficacy Medication side effects Studies do not support the use of potentially toxic agents Do not know most recent studies Reimbursement is too low for checking event recorders and follow-up International Normalized Ratio (INR) levels Antiarrhythmic medications are too confusing 3. Approximately how many patients do you see each week? 4. Approximately what percentage of your patients has AF? 5. Case #1: A 72-year-old woman, with a history of hypertension that is well controlled with amlodipine, presents to her family physician with a history of symptomatic

intermittent palpitations. Her family physician ordered 24-hour Holter monitoring -- during the period of recording, the patient did not report palpitations and the monitor only revealed occasional premature atrial contractions. Blood test results, including those of blood glucose and thyroid function, were normal. Over the course of the next several months, the palpitations persisted. The patient was referred to a cardiologist by her family physician. Physical examination is normal. An event recorder documented several episodes of AF, lasting between several minutes and several hours. Echocardiography was performed, results of which showed normal left ventricular ejection fraction, no valvular abnormalities, and normal wall thickness (no hypertrophy). The patient has no contraindication to anticoagulant therapy and has no history of stroke or transient ischemic attack (TIA). Which stroke risk classification scheme are you most familiar with: (select only one) Framingham Heart Study CHADS2 CHADS1 Stroke Prevention in Atrial Fibrillation (SPAF) American Heart Association (AHA) 6. The CHADS2 stroke risk classification scheme assigns a score based on which of the following? (select only one) 1 point for history of TIA or stroke, age older than 75, history of hypertension, diabetes mellitus (DM), or recent heart failure 2 points for history of TIA or stroke and 1 point for age older than 50, woman, left ventricular hypertrophy, left atrial dilatation 2 points for history of TIA or stroke and 1 point for age older than 75, history of hypertension, DM, or recent heart failure 1 point for age older than 70, hypertension, hypertrophy, atrial dilatation, and mitral stenosis 7. The patient's CHADS2 stroke risk would be classified as? (select only one) Low Moderate High Indeterminate 8. Which antiplatelet-anticoagulant therapy would you recommend for this patient? (select only one) No therapy Aspirin Clopidogrel + aspirin Prasugrel 9. In patients with hypertension and AF, which antihypertensive agents may have beneficial effects in reducing the incidence of AF? (select only one) Calcium-channel blockers

Angiotensin-converting enzyme (ACE) inhibitors Diuretics Antihypertensive drugs have no beneficial effects 10. Case #1 continued: This patient was started on warfarin (INR 2.0- 3.0). One year later, the patient returned to her cardiologist with palpitations, which started 1 week previously. Electrocardiography (ECG) documented AF. Electrical cardioversion was successful. Administration of an antiarrhythmic agent to maintain sinus rhythm is being considered. Administration of dronedarone, compared to placebo, would be expected to: (select only one) Reduce hospitalizations, cardiovascular mortality, and recurrence of AF Reduce AF but have no effect on hospitalizations Have equivalent efficacy to prevent AF but with fewer side effects Reduce total mortality and AF recurrence 11. Case #2: A 54-year-old man with a history of hypertension and diabetes has a 6-month history of intermittent palpitations and AF. His echocardiogram was normal. Results of a perfusion stress test were normal. He underwent anticoagulation therapy with warfarin and then underwent electrical cardioversion, but the AF recurred within 2 months. He is very symptomatic despite good rate control with metoprolol. He now returns to your office for advice regarding optimal management. On the basis of this patient's CHADS2 score and recent studies, what would you recommend for long-term anticoagulation? (select only one) Aspirin Aspirin + clopidogrel Warfarin Either aspirin + clopidogrel or warfarin 12. On the basis of recent studies such as AFFIRM (Atrial Fibrillation Follow-up Investigation of Rhythm Management) or RACE (Rate Control vs Electrical Cardioversion for persistent atrial fibrillation), which strategy do you recommend for reducing mortality or stroke risk? (select only one) Rate control Rhythm control Neither rate nor rhythm control is superior 13. On the basis of the 2006 American College of Cardiology (ACC)/AHA/European Society of Cardiology (ESC) guidelines for antiarrhythmic drugs, which antiarrhythmic agent would be most appropriate for maintenance of sinus rhythm in this patient? (select only one) Type IA agents, such as quinine or procainamide Type III agents, such as dofetilide or sotalol Type IC agents, such as flecainide Amiodarone

14. On the basis of the recently reported studies EURIDIS, ADONIS, and ATHENA would dronedarone (if US Food and Drug Administration approved) be an appropriate therapeutic option to maintain sinus rhythm in this patient? (select only one) Yes No The studies do not apply to this patient I am not aware of these studies 15. Case #3: A 58-year-old man presents to his internist with the complaint of feeling tired and short of breath for several weeks. He has a long-standing history of hypertension and DM, which have been poorly controlled, in part due to poor follow-up and compliance. He had a myocardial infarction 3 years previously. On examination, the patient has tachycardia with an irregularly irregular rhythm, S3 gallop, and crackles at the lung bases. An ECG reveals atrial fibrillation with a rate of 135 beats per minute. The patient's internist sends the patient to the emergency department. In the emergency department, the patient is rate controlled with metoprolol and given intravenous furosemide (Lasix). He is admitted to the cardiology service and an electrophysiology consultation is obtained. A transesophageal echocardiogram is performed, which rules out left atrial thrombus. The left ventricular ejection fraction is 30%. The patient undergoes electrical cardioversion to sinus rhythm. Before discharge, the patient is administered warfarin and a discussion ensues about whether an antiarrhythmic agent should be administered. Treatment of patients with left ventricular (LV) dysfunction after myocardial infarction with -blockers and ACE inhibitors and/or angiotensin II receptor antagonists has been shown to: (select only one) Control heart rate and improve LV function, but have no effect on mortality or incidence of AF Control heart rate, improve LV function, reduce incidence of AF, and prolong survival Control heart rate, improve LV function, prolong survival but have no effect on incidence of AF 16. If an antiarrhythmic is prescribed, which would be the most appropriate in regard to efficacy, tolerability, and safety? (select only one) Flecainide Sotalol Amiodarone Propafenone 17. How would you classify the patient's risk of developing a TIA or stroke? (select only one) Low Intermediate High

18. After several months of follow-up, a stable INR level cannot be established in part due to dietary noncompliance and poor follow-up. In addition, the patient does not wish to have frequent blood tests. Based on the current available data, what would be the most effective regimen to reduce the incidence of stroke in this patient? (select only one) Aspirin Aspirin + clopidogrel Clopidogrel No effective agent other than warfarin for this patient