PracticeUpdate Conference Series - ANZAN 2018

Better Screening for Atrial Fibrillation Needed in PatientsWho PresentWithTIA/Stroke Anticoagulant use among patients who present with transient ischemic attack (TIA) or stroke remains inadequate. Improved screening for atrial fibrillation in patients presenting with TIA or stroke is needed, results of a retrospective chart review show. Z ainab Khan, MD, of Western Sydney University in Penrith, NSW, explained that atrial fibrillation raises risk of

Known atrial fibrillation occurred in 34 (82.9%) stroke admissions and 8 (100%) admissions for TIA. Therefore, atrial fibril- lation was diagnosed post stroke in 17.1% of participants. Prior to stroke and TIA, 61.9% of patients were receiving anticoagulants. Treatment prior to stroke or TIA consisted of 11 (26.2%) on direct oral anticoagulants, 15 (35.7%) on warfarin, 5 (11.9%) on antiplate- lets, and 11 (26.2%) with no antithrombotics. Subtherapeutic international normalized ratios (<2.0) on admission were found in 60% of participants receiving warfarin. Among the 11 untreated patients, one was noncompliant, one had experienced recent subarachnoid hemorrhage, and no explanation was found for the remaining 9 participants. Anticoagulation rates improved on discharge with 40 (81.6%) patients prescribed either direct oral anti- coagulants or warfarin.

Dr. Khan concluded that anticoagulation rates have improved since 2009 (61.9% vs 41%) in stroke/TIA admissions associated with atrial fibrillation. Use of anticoagulants in this population remains inadequate, however. Of patients on warfarin, 60% exhibited subtherapeutic international normalized ratios on admission. A need remains for improved screening for atrial fibrillation. Only a slight decrease in rates of new diagnosis of atrial fibrilla- tion was observed vs the 2009 audit (from 22% to 17.1%). Detection of atrial fibrillation in patients with cryptogenic stroke using an insert- able cardiac monitor was evaluated in terms of cost-effectiveness. Vincent Thijs, MD, of the Florey Institute of Neuroscience andMental Health, University of Melbourne, Victoria, explained that atrial fibrillation needs to be detected prior to Annualized relapse rate, time to first relapse, 24-week confirmed disability worsening, MRI endpoints, and safety were compared between the every-2- week group vs the delayed-treatment group. Over 2 years, the adjusted annualized relapse rate in newly diagnosed patients was 32.3% lower in the peginterferon ß-1a every-2-week group (n=231) than in the delayed-treatment group (n=229; P = .0352). Time to first relapse was longer in the every- 2-week group than in thedelayed-treatment group (P = .0101). The rate of 24-week con- firmed disability worseningwas numerically lower in the every-2-week than in the delayed-treatment group. At year 2, the number of new/newly enhancing T2 lesions was lower in the every-2-week than in the delayed- treatment group (P < .0001), though no difference in the number of gadolinium- enhancing lesions was observed.

potentially fatal or disabling ischemic stroke. Under 70% of eligible patients with atrial fibrillation have been noted to take oral anticoagulants. Dr. Khan and colleagues reviewed med- ical records of patients admitted with stroke/TIA associated with a known or new diagnosis of atrial fibrillation from 2016 to 2017. The data were compared with a similar audit conducted in 2009. Data collected included age, sex, history of atrial fibrillation, adequacy of anticoag- ulation (before and after admission), and vascular risk factors. A total of 49 patients (29 males, average age 76 years) were included. The incidence of atrial fibrillation was found to be 27.9% in stroke and 8.4% among TIA admissions.

Peginterferon ß-1a Improves Clinical and Radiological Outcomes of Patients Newly Diagnosed With RRMS

Consistent with results of the ADVANCE trial, newly diagnosed, treatment- naive patients with relapsing-remitting multiple sclerosis (RRMS) experienced significantly reduced disease activity when administered peginterferon ß-1a every 2 weeks vs patients whose treatment is delayed. T his was a finding of a post hoc sub- evaluation of peginterferon ß-1a in the pivotal phase III, randomized Dr. Newsome and colleagues set out to evaluate the effect of peginterferon ß-1a on clinical and radiological disease activ- ity in newly diagnosed, treatment-naive patients in ADVANCE.

ADVANCE trial. In addition, results of an interim analysis of a 5-year trial of the drug pointed to a tolerability profile consistent with that observed in the pivotal phase III trial were also reported. Scott Douglas Newsome, DO, of Johns Hopkins University School of Medicine in Baltimore, Maryland, explained that the pivotal phase III ADVANCE study evaluated the efficacy of subcutaneous peginterferon ß-1a 125 µg every 2 weeks in patients with RRMS. Approximately 45% of participants had been newly diagnosed and had received no prior disease-mod- ifying therapy.

ADVANCE was a 2-year, double-blind study. In year 1, patients were randomized to peginterferon ß-1a every 2 or 4 weeks or placebo. In year 2, patients who were receiving placebo were re-randomized to peginterferon ß-1a every 2 or 4 weeks (delayed-treatment group). The present analysis assessed the sub- group of patients diagnosed ≤1 year prior to enrollment who had received no prior disease-modifying therapy.

12 PRACTICEUPDATE CONFERENCE SERIES • ANZAN 2018