atrialatrial fibrillation: fibrillation: perspective

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AtrialAtrial Fibrillation: Fibrillation: Guidelines through Guidelines through clinical casesclinical cases andandclinical cases clinical cases and and

2010 2010 updates updates Samy Claude ELAYISamy Claude ELAYI

Cardiac Clinical Pacing and ElectrophysiologyCardiac Clinical Pacing and ElectrophysiologyUKUK

AF: PUBLIC HEALTH AF: PUBLIC HEALTH PERSPECTIVEPERSPECTIVE

World incidence720, 000 new cases / year

World prevalence5 5 illi

Feinberg WM: Arch Intern Med 1995/ Murgatroyd F and Camm AJ: Lancet 1993

5.5 million

AF prevalence increasing with aging of population

Clinical case 1Clinical case 1

65 yo male65 yo male PMH: HTNPMH: HTN

Meds: metoprolol 50 mg BIDMeds: metoprolol 50 mg BID Meds: metoprolol 50 mg BID Meds: metoprolol 50 mg BID Comes for regular f/u visit, no symptomsComes for regular f/u visit, no symptoms

with a normal daily activity.with a normal daily activity. Clinically: irregular heart beat.Clinically: irregular heart beat.

You discussed with the patient the potentialYou discussed with the patient the potentialrisk of stroke. What medication would yourisk of stroke. What medication would youconsider daily regarding this risk?consider daily regarding this risk?y g gy g g No medicationNo medication Start Aspirin 81 mgStart Aspirin 81 mg Start Aspirin 325 mgStart Aspirin 325 mg Start PlavixStart Plavix Start CoumadinStart Coumadin

______________________________________________________________________________________________________________________________________________ModerateModerate--Risk Factors HighRisk Factors High--Risk Factors_________Risk Factors_________

Heart failure Previous stroke, TIA or embolismHeart failure Previous stroke, TIA or embolism

Hypertension Mitral stenosisHypertension Mitral stenosis

Age greater than or equal to 75 y Age greater than or equal to 75 y

LV ejection fraction 35% or lessLV ejection fraction 35% or less

Diabetes mellitusDiabetes mellitus__________________________________________________________________________________________________________________________________________________________________________________________________________________________________

STROKE RISK/ ANTITHROMBOTIC THERAPY AND AF

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Risk Category Recommended Therapy_Risk Category Recommended Therapy_

No risk factors Aspirin 81 to 325mg/day or nonNo risk factors Aspirin 81 to 325mg/day or nonee**

One moderateOne moderate--risk factor Aspirin 81 to 325 mg daily, or warfarin (INRrisk factor Aspirin 81 to 325 mg daily, or warfarin (INR2.0 to 3.0, target 2.5)2.0 to 3.0, target 2.5)

Any high risk factor or >1 moderate risk factor warfarin (INR 2.0 to 3.0, target 2.5)Any high risk factor or >1 moderate risk factor warfarin (INR 2.0 to 3.0, target 2.5)

* Age less than 60 y, no heart disease (lone AF)

2006 guidelines for the management of patients with AF

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Stroke risk and CHADS2 scoreStroke risk and CHADS2 scoreFor non valvular AFFor non valvular AFnn CCongestive Heart Failure +1ongestive Heart Failure +1nn HHypertension +1ypertension +1nn AAge > 75 yo +1ge > 75 yo +1nn DDiabetes +1iabetes +1

P iP i SSt k /TIAt k /TIA 22nn PriorPrior SStroke/TIA +troke/TIA +22

Then classification as:Then classification as: LowLow--risk = 0risk = 0 IntermediateIntermediate--risk = 1risk = 1--22 HighHigh--risk >2risk >2


Heart failure Previous stroke, TIA or embolismHeart failure Previous stroke, TIA or embolism


Age greater than or equal to 75 y Age greater than or equal to 75 y




A

D

H

C S2

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________







You discussed with the patient the potentialYou discussed with the patient the potentialrisk of stroke. What would you do next regardingrisk of stroke. What would you do next regardingthis risk?this risk? Not start anythingNot start anything Start Aspirin 81 mgStart Aspirin 81 mg Start Aspirin 325 mgStart Aspirin 325 mg Start PlavixStart Plavix Start CoumadinStart Coumadin

You decided to start Aspirin and determine You decided to start Aspirin and determine during the f/u that your patient has during the f/u that your patient has persistent AF. persistent AF. pp

AF CLASSIFICATIONAF CLASSIFICATION

PAROXYSMALPAROXYSMALAFAF

PERSISTENT PERSISTENT AFAF

PERMANENT PERMANENT AFAF

TerminatesTerminates YY NN NNTerminates Terminates spontaneouslyspontaneously

YesYes NoNo NoNo

AF can be AF can be converted to SRconverted to SR(DCV or AADs)(DCV or AADs)

N/AN/A YesYes NoNo

Gallagher MM, Camm AJ. Classification of atrial fibrillation. PACE. 1992;20:1603-1605

What would you do next for this patient with What would you do next for this patient with HTN and asymptomatic persistent AF?HTN and asymptomatic persistent AF?

Cardiovert the patient Cardiovert the patient Cardiovert the patient and start long termCardiovert the patient and start long term Cardiovert the patient and start long term Cardiovert the patient and start long term

antiarrhythmic drugsantiarrhythmic drugs Keep the metoprolol and adjust the dose to keep Keep the metoprolol and adjust the dose to keep

baseline heart rate <80 bpm and exercise heart baseline heart rate <80 bpm and exercise heart rate<110 bpm to avoid potential tachycardia rate<110 bpm to avoid potential tachycardia induced cardiomyopathy and heart failureinduced cardiomyopathy and heart failure

Send the patient for an ablationSend the patient for an ablation

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ACC/AHA/ESC guidelines 2006ACC/AHA/ESC guidelines 2006


Rate control Rhythm control


What would you do next for this patient with What would you do next for this patient with HTN and asymptomatic persistent AF?HTN and asymptomatic persistent AF?

Cardiovert the patient (Cardiovert the patient (RHYTHM CONTROL)RHYTHM CONTROL) Cardiovert the patient and start long termCardiovert the patient and start long term Cardiovert the patient and start long term Cardiovert the patient and start long term

antiarrhythmic drugsantiarrhythmic drugs Keep the metoprolol and adjust the dose to keep Keep the metoprolol and adjust the dose to keep

baseline heart rate <80 bpm and exercise heart baseline heart rate <80 bpm and exercise heart rate<110 bpm to avoid potential tachycardia rate<110 bpm to avoid potential tachycardia induced cardiomyopathy (induced cardiomyopathy (RATE CONTROLRATE CONTROL))

Send the patient for an ablationSend the patient for an ablation

Design in the mid 1990 to help manage AF Design in the mid 1990 to help manage AF

Potential benefit of maintaining SR: Potential benefit of maintaining SR: better survivalbetter survival

Rate vs. Rhythm controlRate vs. Rhythm controlThe AFFIRM TrialThe AFFIRM Trial

better survivalbetter survivallower risk of strokelower risk of strokebetter quality of life better quality of life

HypothesisHypothesis: maintenance of SR : maintenance of SR with AADswith AADswould improve mortality compared to rate would improve mortality compared to rate control of AF with AV nodal blockerscontrol of AF with AV nodal blockers

AFFIRM NEJM 2002;347:1825-33

Inclusion criteriaInclusion criteria

One or more recent episodes of AF of > 6 hours (excluded permanent AF). Patients with at least one clinical risk factor for


Patients with at least one clinical risk factor for stroke:

age> 65HTNDMCHFLVEF < 0.40 prior stroke

AFFIRM NEJM 2002;347:1825-33

Patients with frequent or severe Patients with frequent or severe symptomssymptoms were largely excludedwere largely excluded

Although this subgroup would benefit the most from SRAlthough this subgroup would benefit the most from SR

AFFIRM limitationAFFIRM limitation

Constitutes >1/3 of all AF patientsConstitutes >1/3 of all AF patients

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4060 patients were randomized to:

1. Rhythm control (maintain SR as much


as possible using AADS and DCV).

2. Rate control (with AV nodal blockers).

AFFIRM NEJM 2002;347:1825-33

Primary endpoint: overall mortalityPrimary endpoint: overall mortality

“Management of AF with the rhythm“Management of AF with the rhythm--control strategy control strategy offers no survival advantage over the rateoffers no survival advantage over the rate--control control strategy”strategy”

It does not mean SR=AF in term of mortality.It does not mean SR=AF in term of mortality.

AFFIRM study did not compare SR vs AF, but: AFFIRM study did not compare SR vs AF, but: an ineffective and toxic tool to maintain SR (AADs) an ineffective and toxic tool to maintain SR (AADs)

versusversusmaintaining AF with rate control drugs.maintaining AF with rate control drugs.

Sinus Rhythm vs. AFSinus Rhythm vs. AF

AFFIRM study can not be extrapolated to “Sinus AFFIRM study can not be extrapolated to “Sinus rhythm and AF are equivalent in term of mortality”. rhythm and AF are equivalent in term of mortality”.

SR is better than AF mortality wise.SR is better than AF mortality wise.

Clinical impact of AF on mortalityClinical impact of AF on mortality

AF has a 1.5AF has a 1.5-- to 1.9to 1.9--fold increased risk of fold increased risk of mortality in the general population mortality in the general population * * compared to sinus rhythmcompared to sinus rhythm

4.24.2--fold increased risk for CV mortality in lone AF; fold increased risk for CV mortality in lone AF;

2.52.5--fold increased risk for mortality in HF;fold increased risk for mortality in HF;

4.54.5--fold increased risk for mortality in acute coronary syndromes.fold increased risk for mortality in acute coronary syndromes.

** Benjamin et al Circulation 1998;98:946Benjamin et al Circulation 1998;98:946--5252

AFFIRM conclusion:AFFIRM conclusion:Trying to maintain sinus rhythm with an aggressive Trying to maintain sinus rhythm with an aggressive strategy using AADS (generally ineffective to maintain strategy using AADS (generally ineffective to maintain SR and with potential life threatening side effects) is SR and with potential life threatening side effects) is p g )p g )not better in term of mortality than keeping AF rate not better in term of mortality than keeping AF rate controlled in patients with moderately, minimally or controlled in patients with moderately, minimally or not symptomatic AF.not symptomatic AF.

The impact of maintaining SR on mortality with The impact of maintaining SR on mortality with ablation or potential new drugs (less toxic, more ablation or potential new drugs (less toxic, more effective to maintain SR) is unknown.effective to maintain SR) is unknown.

65 yo male HTN metoprolol asymptomatic 65 yo male HTN metoprolol asymptomatic persistent AF persistent AF You decided to cardiovert the patient and this You decided to cardiovert the patient and this restored normal sinus rhythm However 4restored normal sinus rhythm However 4restored normal sinus rhythm. However, 4 restored normal sinus rhythm. However, 4 months latter, he is back in AF and still months latter, he is back in AF and still asymptomatic.asymptomatic.What would you do next?What would you do next?

Start cardioversion again Start cardioversion again rate control the AFrate control the AF

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65 yo male HTN metoprolol 65 yo male HTN metoprolol asymptomatic asymptomatic recurrent persistent AFrecurrent persistent AFYou decided to cardiovert the patient and this You decided to cardiovert the patient and this restored normal sinus rhythm However 4restored normal sinus rhythm However 4restored normal sinus rhythm. However, 4 restored normal sinus rhythm. However, 4 months latter, he is back in AF and still months latter, he is back in AF and still asymptomatic.asymptomatic.What would you do next?What would you do next?

Start cardioversion again Start cardioversion again Rate control the AF Rate control the AF

Clinical case 2Clinical case 2 61 year old male 61 year old male PMH: HTN treated with amlodipine PMH: HTN treated with amlodipine Complaining of episodes of palpitations for the Complaining of episodes of palpitations for the

last year: several episodes/month, from few last year: several episodes/month, from few i 1 h i i F li 1 h i i F lminutes to 1 hour spontaneous termination. Feels minutes to 1 hour spontaneous termination. Feels

dizzy, SOB and exhausted.dizzy, SOB and exhausted. He went to the local ED 6 weeks ago and was He went to the local ED 6 weeks ago and was

told he has "Atold he has "A--fib." Had heart echo/TSH done. fib." Had heart echo/TSH done. Was started on ASA and metoprolol 150 mg BID Was started on ASA and metoprolol 150 mg BID and asked to f/u with his PCP. and asked to f/u with his PCP.

Clinical exam: unremarkable with regular heart Clinical exam: unremarkable with regular heart beatbeat

The patient still has frequent arrhythmia The patient still has frequent arrhythmia symptoms despite 150 mg BID of metoprolol. symptoms despite 150 mg BID of metoprolol. What would you do next?What would you do next?

Consider increasing metoprololConsider increasing metoprolol Consider starting antiarrhythmic drugsConsider starting antiarrhythmic drugs Consider sending the patient for an AF ablationConsider sending the patient for an AF ablation Consider sending the patient for a pacemaker Consider sending the patient for a pacemaker

and AV node junction ablationand AV node junction ablation


The patient still have frequent arrhythmia The patient still have frequent arrhythmia symptoms despite 300 mg of metoprolol. What symptoms despite 300 mg of metoprolol. What would you do next?would you do next?

Consider increasing metoprololConsider increasing metoprolol Consider starting antiarrhythmic drugsConsider starting antiarrhythmic drugs Consider sending the patient for an AF ablationConsider sending the patient for an AF ablation Consider sending the patient for a pacemaker Consider sending the patient for a pacemaker

and AV node junction ablationand AV node junction ablation

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AADs used for AF in 2009AADs used for AF in 2009FOR RHYTHM CONTROLFOR RHYTHM CONTROL (SR)(SR)

Class ICClass ICFlecainide (Tambocor*)Flecainide (Tambocor*)Propafenone (Rythmol*)Propafenone (Rythmol*)

Class IIIClass III Class IIIClass IIIAmiodarone (Cordarone*;Pacerone*)Amiodarone (Cordarone*;Pacerone*)Sotalol (Betapace*)Sotalol (Betapace*)Dofetilide (Tikosyn*)Dofetilide (Tikosyn*)Dronedarone (Multaq*)Dronedarone (Multaq*)

FOR RATE CONTROLFOR RATE CONTROL (AF)(AF)

Betablockers/ calcium blockers (diltiazem/verapamil)/ digoxinBetablockers/ calcium blockers (diltiazem/verapamil)/ digoxin

61 yo male HTN normal heart echo no 61 yo male HTN normal heart echo no CAD nor heart failure very symptomatic AF CAD nor heart failure very symptomatic AF failed rate control.failed rate control.

Which antiarrhythmic could be started?Which antiarrhythmic could be started?

61 yo male HTN normal heart echo no 61 yo male HTN normal heart echo no CAD nor heart failure very symptomatic AF CAD nor heart failure very symptomatic AF failed rate control.failed rate control.

Which antiarrhythmic could be started?Which antiarrhythmic could be started? Depends on the heart conditionDepends on the heart condition


The patient was started on flecainide 50 mg The patient was started on flecainide 50 mg BID, well tolerated. At his 2 months f/u, he BID, well tolerated. At his 2 months f/u, he reports a few episodes of AF<5 min still reports a few episodes of AF<5 min still symptomatic What would you consider?symptomatic What would you consider?symptomatic. What would you consider?symptomatic. What would you consider?

Continue same medications and f/u Continue same medications and f/u Increase the dose of flecainide to the standard Increase the dose of flecainide to the standard

dose of 100 mg BIDdose of 100 mg BID Change AADsChange AADs Consider sending the patient for an AF ablationConsider sending the patient for an AF ablation

The patient was started on flecainide 50 mg The patient was started on flecainide 50 mg BID, well tolerated. At his 2 months f/u, he BID, well tolerated. At his 2 months f/u, he reports a few episodes of AF<5 min still reports a few episodes of AF<5 min still symptomatic What would you consider?symptomatic What would you consider?symptomatic. What would you consider?symptomatic. What would you consider?

Continue same medications and f/u Continue same medications and f/u Increase the dose of flecainide to the standard Increase the dose of flecainide to the standard

dose of 100 mg BIDdose of 100 mg BID Change AADsChange AADs Consider sending the patient for an AF ablationConsider sending the patient for an AF ablation

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You increased the flecainide to 100 mg BID. The You increased the flecainide to 100 mg BID. The patient did well and did not came back to see patient did well and did not came back to see you for seven months.you for seven months.

One day, he calls and wants to been seen One day, he calls and wants to been seen quickly because he is short of breath and has quickly because he is short of breath and has bilateral pedal edema for the last few days.bilateral pedal edema for the last few days.

Clinically, he is tachycardic around 160 bpm Clinically, he is tachycardic around 160 bpm irregular and is in congestive heart failure with irregular and is in congestive heart failure with bilateral crackles and a systolic BP of 90 mmHG.bilateral crackles and a systolic BP of 90 mmHG.

You send him to the ER where he was admitted.You send him to the ER where he was admitted.His left ventricular EF is now 30% on echo. His left ventricular EF is now 30% on echo. What do you expect them to do?What do you expect them to do?

Keep the patient on aspirinKeep the patient on aspirin Initiate coumadinInitiate coumadin Cardiovert the patient to sinus rhythm after TEECardiovert the patient to sinus rhythm after TEE Initiate long term amiodaroneInitiate long term amiodarone Initiate immediately dronedarone (Multaq*)Initiate immediately dronedarone (Multaq*)


Age greater than or equal to 75 y Previous stroke, TIA or embolismAge greater than or equal to 75 y Previous stroke, TIA or embolism


Heart failureHeart failure




__________________________________________________________________________________________________________________________________________________________________________________________________________________________________







You send him to the ER where he was admitted.You send him to the ER where he was admitted.His left ventricular EF is 30% on echo. What do His left ventricular EF is 30% on echo. What do you expect them to do?you expect them to do?


Amiodarone the most effective but sideAmiodarone the most effective but sideeffects +++:effects +++:life threatening pulmonary fibrosislife threatening pulmonary fibrosis--life threatening pulmonary fibrosislife threatening pulmonary fibrosis

--thyroid (hyper or hypo)thyroid (hyper or hypo)--QT prolongation (ventricular arrhythmias)QT prolongation (ventricular arrhythmias)--ocular, neurologic, dermatologic, liver…ocular, neurologic, dermatologic, liver…

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Class III K blockersClass III K blockers Available in the US since august 2009Available in the US since august 2009

Dronedarone (Multaq*)Dronedarone (Multaq*)

Wei Sun et al Circ 1999;100:2276-2281

Dronedarone (Multaq*)Dronedarone (Multaq*)

AdvantagesAdvantages--does not seem to have lung or thyroid toxicitydoes not seem to have lung or thyroid toxicity (with a half(with a halflife <24h)life <24h)--reduces hospitalization for AF (ATHENA trial NEJM 2009)reduces hospitalization for AF (ATHENA trial NEJM 2009)p ( )p ( )--no hospital admission for initiation/ no special certificationno hospital admission for initiation/ no special certification

LimitsLimits--ContraContra--indication in unstable indication in unstable heart failureheart failure (IV) or class II(IV) or class IIIII< 1 monthIII< 1 month--efficacy less than amiodarone (efficacy less than amiodarone (--12%) 12%)

DronedaroneDronedarone

Dronedarone

Dronedarone

Dronedarone?




The patient has been cardioverted. Patient The patient has been cardioverted. Patient has been discharged on coumadin and has been discharged on coumadin and Tikosyn 500 mcg BID (maximal dose).Tikosyn 500 mcg BID (maximal dose).

He comes at his 2 months f/u after He comes at his 2 months f/u after repeating a new heart echo: EF 70% repeating a new heart echo: EF 70% (arrhythmia induced cardiomyopathy). (arrhythmia induced cardiomyopathy).

He still reports palpitations and dizziness He still reports palpitations and dizziness which are impairing his quality of life.which are impairing his quality of life.

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So 61 yo male HTN very symptomatic AFSo 61 yo male HTN very symptomatic AFfailed two AADS at maximal doses.failed two AADS at maximal doses.What would you do next?What would you do next?What would you do next?What would you do next? Stop the tikosyn and start sotalolStop the tikosyn and start sotalol Send the patient for AF ablationSend the patient for AF ablation

So 61 yo male HTN very symptomatic AFSo 61 yo male HTN very symptomatic AFfailed two AADS at maximal doses.failed two AADS at maximal doses.What would you do next?What would you do next?What would you do next?What would you do next? Stop the tikosyn and start sotalolStop the tikosyn and start sotalol Send the patient for AF ablationSend the patient for AF ablation

I

II

IIIaVraVl

aVfaVf

V1V2V3V4

V5

V6

Posterior Basal View Posterior Basal View ––Left AtriumLeft Atrium

R. superior pulmonary vein L. auricle

L. pulmonary artery

R. pulmonary artery

R. inferior pulmonary vein

Coronary sinus

L. inferior pulmonary vein

L. atrium

L. superior pulmonary vein

Netter F. Atlas of Human Anatomy. 1989;Plate 202.

LSPVLSPVLSPV

Veno-atrialjunction

Veno-atrialjunction

LunghilumLunghilum

Myocardial sleeveMyocardial sleeve

LALSPVLSPVLSPV

LeftatriumLeftatrium

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Atrial Fibrillation: Catheter ablation of PV focusAtrial Fibrillation: Catheter ablation of PV focus

The fluoroscopy images The fluoroscopy images show the ablation catheter show the ablation catheter (ABL) in the left anterior (ABL) in the left anterior oblique (LAO) and right oblique (LAO) and right anterior oblique (RAO) anterior oblique (RAO) projections.projections.

Circular mapping catheter

Esophagus temperature monitoring probe

LA CT to define the anatomy more precisely

Complex procedure

Straight mapping catheter

Intracardiac echo probe

catheterAblation catheter

Mapping system during ablation

Paroxysmal AFParoxysmal AF

Targets mainly the trigger by Targets mainly the trigger by disconnecting the pulmonary veins from disconnecting the pulmonary veins from the rest of the left atriumthe rest of the left atrium

Ablation in paroxysmal AFAblation in paroxysmal AF

Elayi et al. Heart rhythm 2006

Persistent AFPersistent AF

May need to target May need to target --the trigger (isolation of the pulmonary the trigger (isolation of the pulmonary veins)veins)veins)veins)--the rest of the left atrium and sometimes the rest of the left atrium and sometimes right atrium (to modify the atrial substrate right atrium (to modify the atrial substrate capable of sustaining persistent AF)capable of sustaining persistent AF)

Ablation in persistent AFAblation in persistent AF

Elayi et al. Heart rhythm 2008

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Main complications of AF ablationMain complications of AF ablation

StrokeStroke (0.5 to 1%)+++ like left heart cath(0.5 to 1%)+++ like left heart cath Pericardial effusion/tamponnadePericardial effusion/tamponnade

Others: hematomas;Others: hematomas; PV stenosis;PV stenosis; fistulafistula Others: hematomas; Others: hematomas; PV stenosis;PV stenosis; fistula fistula with esophagus, phrenic nerve paralysis…with esophagus, phrenic nerve paralysis…

Ablation versus AADsAblation versus AADs

AdvantagesAdvantages--EfficacyEfficacy--Potential cure (no life long treatment) Potential cure (no life long treatment) DC di t ti llDC di t ti ll--DC coumadin potentiallyDC coumadin potentially

DisadvantagesDisadvantages--Immediate procedure riskImmediate procedure risk--Operator dependant (long learning curve)Operator dependant (long learning curve)--Lack on very long term data/datas on mortalityLack on very long term data/datas on mortality


Maintenance of sinus rhythmMaintenance of sinus rhythmCatheter ablation is a reasonable alternative Catheter ablation is a reasonable alternative to pharmacological therapy to prevent to pharmacological therapy to prevent recurrent AF in symptomatic patients withrecurrent AF in symptomatic patients withrecurrent AF in symptomatic patients with recurrent AF in symptomatic patients with little or no LA enlargementlittle or no LA enlargement (Class IIA; level of (Class IIA; level of evidence C)evidence C)


AF Ablation summaryAF Ablation summary

Effective procedure with a success rate around 70Effective procedure with a success rate around 70--90% in paroxysmal AF and 5090% in paroxysmal AF and 50--70% in persistent AF70% in persistent AF(less successful in enlarged atrium).(less successful in enlarged atrium).FF t tit ti AFAF For For symptomaticsymptomatic AFAF

After failure of at least one AADAfter failure of at least one AAD With potential significant complicationsWith potential significant complications Whether improves long term survival or not Whether improves long term survival or not

unknownunknown

Future: DabigatranFuture: Dabigatran

Oral direct thrombin inhibitorOral direct thrombin inhibitor Advantages over coumadin/enoxaparin:Advantages over coumadin/enoxaparin:

--oraloral--no routine anticoagutation checksno routine anticoagutation checks--few drugs interactionfew drugs interaction

Disavantages:Disavantages:--BID with short half life (compliance)BID with short half life (compliance)--Liver toxicityLiver toxicity

RE-LY trial NEJM 2009

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DabigatranDabigatran

Was compared to coumadin at two doses Was compared to coumadin at two doses (RE(RE--LY trial):LY trial):--110 mg BID: same embolic stroke rate 110 mg BID: same embolic stroke rate ggbut less hemorrhagic stroke than but less hemorrhagic stroke than coumadin.coumadin.--150 mg BID: less embolic stroke but 150 mg BID: less embolic stroke but same hemorrhagic stroke than coumadinsame hemorrhagic stroke than coumadin

FDA approval targeted for 2010FDA approval targeted for 2010

RE-LY trial NEJM 2009

ConclusionConclusion Several Rx options are available for AFSeveral Rx options are available for AF

Need to individualize therapy based on patient Need to individualize therapy based on patient characteristicscharacteristics

Asymptomatic patientsAsymptomatic patients: : Make sure patient really asymptomaticMake sure patient really asymptomatic--Make sure patient really asymptomaticMake sure patient really asymptomatic

--Rate control is an acceptable option (try DCV Rate control is an acceptable option (try DCV once reasonable) once reasonable) (Target HR 80bpm rest and 110bpm exercise)(Target HR 80bpm rest and 110bpm exercise)

Symptomatic patientsSymptomatic patients::--AADs are always the first optionAADs are always the first option--Failure of AADs : AF ablation Failure of AADs : AF ablation

Thank you very muchThank you very much

If further questions:If further questions:Email:samyEmail:[email protected]@uky.eduPhone:(859)Phone:(859)--32356303235630


87 yo female87 yo female PMH: HTN DM several surgeries COPD PMH: HTN DM several surgeries COPD AF: permanent with several hospitalizations over AF: permanent with several hospitalizations over p pp p

the last 2 years for CHF and ventricular heart the last 2 years for CHF and ventricular heart rate in the 160rate in the 160--170 despite digoxin and 170 despite digoxin and metoprolol which alternates with episodes of metoprolol which alternates with episodes of heart rate in the 30’s very tired and dizzyheart rate in the 30’s very tired and dizzy

Clinically systolic BP in the 90’sClinically systolic BP in the 90’s

What would you do next?What would you do next? Add another AV nodal blockers (diltiazem)Add another AV nodal blockers (diltiazem)

Send the patient for a pacemakerSend the patient for a pacemaker Send the patient for a pacemakerSend the patient for a pacemaker Send the patient for a pacemaker and AV Send the patient for a pacemaker and AV

node ablationnode ablation

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AVN ABLATION AND PACEMAKERAVN ABLATION AND PACEMAKER

Rationale: Rationale: AVN ablation prevent the fast atria AVN ablation prevent the fast atria

t (500 b ) t d t idlt (500 b ) t d t idlrate (500 bpm) to conduct rapidly rate (500 bpm) to conduct rapidly and irregularly to the ventricle by and irregularly to the ventricle by disconnecting atria and ventricles disconnecting atria and ventricles

The ventricle can be paced regularly.The ventricle can be paced regularly.

AV Node AblationAV Node Ablation

AV Node AblationAV Node Ablation

AVN ablation and pacingAVN ablation and pacing

Only for selected patients with: Only for selected patients with: symptomatic AF symptomatic AF failed AADs (rhythm or rate control)failed AADs (rhythm or rate control) not good candidate for ablationnot good candidate for ablation


64 yo male 64 yo male h/o GERD Comes to see you in regular f/u h/o GERD Comes to see you in regular f/u

visit used to be very active but nowvisit used to be very active but nowvisit. used to be very active but now visit. used to be very active but now cannot do any significant effort because of cannot do any significant effort because of fatigue so limit his activity and doing OK fatigue so limit his activity and doing OK

Clinically irregular heart beat 85 bpmClinically irregular heart beat 85 bpm

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You do a general workup (CBC…) than isYou do a general workup (CBC…) than isnegative. What would you do next?negative. What would you do next?

f/u in a few monthsf/u in a few months f/u in a few monthsf/u in a few months Do a 24 hours holter to make sure he is Do a 24 hours holter to make sure he is

correctly rate controlledcorrectly rate controlled Try to cardiovert himTry to cardiovert him

Assess symptoms is criticalAssess symptoms is critical

Hemodynamics Hemodynamics SymptomsSymptoms

because it is going to guide yourbecause it is going to guide yourtreatmenttreatment

Reduced cardiac output Reduced cardiac output --Hypotension Hypotension --Pulmonary and/or systemic CHFPulmonary and/or systemic CHFF t/ l /i l t i l t iF t/ l /i l t i l t i


Fast/slow/irregular ventricular rate is Fast/slow/irregular ventricular rate is symptomatic for many patients, resulting in:symptomatic for many patients, resulting in: PalpitationsPalpitations DyspneaDyspnea DizzinessDizziness Post conversion pauses/ syncopePost conversion pauses/ syncope

Inappropriate increases in heart rate Inappropriate increases in heart rate with exercise may cause with exercise may cause --exercise intolerance +++ exercise intolerance +++


--fatigue +++fatigue +++If chronicIf chronic cardiomyopathy with low EFcardiomyopathy with low EF

Increase myocardial oxygen demand Increase myocardial oxygen demand may precipitate may precipitate coronary ischemia.coronary ischemia.

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(ACC/AHA/ESC 2006 guidelines for the managementof patients with atrial fibrillation)

CONCLUSIONCONCLUSION Several AF treatment options available Several AF treatment options available AADs always 1AADs always 1stst option to rhythm control before ablation option to rhythm control before ablation Rate control is an acceptable primary therapy:Rate control is an acceptable primary therapy:

--if reach target (80 bpm at rest and 110 bpm exercise)if reach target (80 bpm at rest and 110 bpm exercise)--consider DCV for the 1consider DCV for the 1stst documented AF, even if not documented AF, even if not symptomaticsymptomatic--no data to compare mortality with ablation and rate no data to compare mortality with ablation and rate controlcontrol

Patient stays symptomatic despite rate/rhythm control Patient stays symptomatic despite rate/rhythm control consider ablationconsider ablation

AVN ablation+ pacemaker AVN ablation+ pacemaker last resortlast resort

Atrial fibrillation conducting quickly to the Atrial fibrillation conducting quickly to the ventricles can lead to tachycardia induced ventricles can lead to tachycardia induced dilated cardiomyopathy with low ventricle dilated cardiomyopathy with low ventricle

Symptoms and AF (2)Symptoms and AF (2)

y p yy p yejection fraction.ejection fraction.

If rate control strategy is chosen, rate If rate control strategy is chosen, rate control should be efficient. control should be efficient.

Dronedarone jeff emailDronedarone jeff email

Multaq is contraindicated in patients with NYHA Class IV heart Multaq is contraindicated in patients with NYHA Class IV heart failure, or NYHA Class IIfailure, or NYHA Class II--III heart failure with a recent III heart failure with a recent decompensation requiring hospitalization or referral to a specialized decompensation requiring hospitalization or referral to a specialized heart failure clinic.heart failure clinic. The Athena trial characterized recent The Athena trial characterized recent decompensation as occurring in the previous 4 weeks.decompensation as occurring in the previous 4 weeks. No criteria No criteria were used for ejection fraction however Athena had 1165 patientswere used for ejection fraction however Athena had 1165 patientswere used for ejection fraction however Athena had 1165 patients were used for ejection fraction however Athena had 1165 patients with Class 1 or 2 CHF and 200 patients with Class 3.with Class 1 or 2 CHF and 200 patients with Class 3. There were There were 179 patients with a LVEF <35% and 4365 patients with LVEF 179 patients with a LVEF <35% and 4365 patients with LVEF >35%.>35%.

If a patient has CHF Class 1, 2, or 3, has a normal EF, and is If a patient has CHF Class 1, 2, or 3, has a normal EF, and is Clinically stable.Clinically stable. Multaq may be used just as it was in Athena.Multaq may be used just as it was in Athena. If If they are becoming unstable they should not be started or the they are becoming unstable they should not be started or the medication should be stopped.medication should be stopped.

dronedaronedronedarone

Pros:Pros:--no hospital admission/ drug certificationno hospital admission/ drug certification--no renal excretionno renal excretion--should replace IC drugsshould replace IC drugs--multi channel, also AV nodal blocade (per rep, dim HR in AF by 10multi channel, also AV nodal blocade (per rep, dim HR in AF by 10--1515multi channel, also AV nodal blocade (per rep, dim HR in AF by 10multi channel, also AV nodal blocade (per rep, dim HR in AF by 10 15 15

bpm)bpm)

Cons:Cons:--longer study f/u 1.5 yearlonger study f/u 1.5 year--efficacy efficacy --12% compared to amiodarone (dionysos)12% compared to amiodarone (dionysos)QTQT--indicated in parox AFindicated in parox AF--CI in class IV and class 2 to 3 recent within one month= unstable CHFCI in class IV and class 2 to 3 recent within one month= unstable CHF

His main concern is the risk of stroke His main concern is the risk of stroke (father had a massive stroke). What would (father had a massive stroke). What would you do regarding his treatment:you do regarding his treatment:y g gy g g

Keep on ASAKeep on ASA Stop ASA and start clopidogrel (Plavix)Stop ASA and start clopidogrel (Plavix) Stop ASA and start coumadinStop ASA and start coumadin

5/5/2010

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ACC/AHA/ESC guidelines 2006ACC/AHA/ESC guidelines 2006

Rx options for recurrent AFRx options for recurrent AFRhythm controlRhythm control [keep the patient in SR][keep the patient in SR]

with antiarrhythmics drugs (AADs)with antiarrhythmics drugs (AADs)

with ablationwith ablation-- Catheter ablationCatheter ablationCatheter ablation Catheter ablation -- Surgery (Maze)Surgery (Maze)

With hybrid approach: combining AADs and/or ablation With hybrid approach: combining AADs and/or ablation and/or pacemakersand/or pacemakers

Rate controlRate control [keep patient in AF but control ventricular rate][keep patient in AF but control ventricular rate]

with AV nodal blockerswith AV nodal blockers

with AV nodal ablation and pacemakerwith AV nodal ablation and pacemaker

atrialatrial fibrillation: fibrillation: perspective

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