Martin Siegfried, M.D• Cardiologist at the CardioVascular

Group/Gwinnett Medical Group

• Board Certified in Cardiovascular Diseases

• He is a Member of the American College of Cardiology

• Special interests include Coronary Artery Disease, Stress Testing, and Cardiac Echocardiography.

Medical School:Thomas Jefferson University

Residency: Emory University

Hospital

Fellowship: Emory University

Hospital

A fib in Special Situations

Disclosures

• No financial disclosures

Post Op Afib

Post OP• Possible causes– Hypoxia– Hypokalemia and hypomagnesemia– Pericarditis– Hyper-adrenergic state– Inflammation

Cardiac Post OP• Increasing age • Preop AF• Large LA• Prior Cardiac surgery• Mitral valve disease• Chronic obstructive pulmonary disease (COPD)• Increased hemoglobin A1c • Poor physical activity in the year prior to surgery• Caucasian race • Obesity • Lack of beta-blocker or ACE inhibitor• Elevated BNP• Severe right coronary artery stenosis • Hypokalemia and hypomagnesemia

Post Op

• Post op CABG 15-40%• Post op Valve 37-50%• Post op CABG + Valve 60%

Clinical Implications

• Increased incidence of PO complications• Longer hospital stay• More likely to develop hypotension,

pulmonary edema and CVA (3.3% vs. 1.4%)• Lower in-hospital as well as long term survival• Cost of care of PO AF $~10,000/patient

PostOp

• Timing– Occurs by day 2 or 3 post op– 15-30% convert within two hours and up to 80%

in 24 hours– The mean duration 11-12 hours and more than

90% in sinus rhythm 6-8 weeks post op– 3 of 116 were still in AF at six weeks

Various sources

Question 1

• Mrs J. develops afib with generally controlled rates on post op CABG day 3. The next step in her management is?

A) Synchronized CardioversionB) Intravenous Amiodarone

C) Beta-blockers and AnticoagulationD) Observation

Post OP

Intra Operative Measures to Reduce Post Cardiac Surgery A fib• Off-pump CABG• Preservation of the anterior fat pad

You are asked to see a patient for pre-op clearance for CABG. Patient is a white male 76 years old with PMH of HTN and DM. Medications include apart from others metoprolol tartrate 50mg bid, lisinopril 10mg daily, ASA, Insulin.Exam: BP: 120/88 P-78 systemic exam normal.With regards prevention of postoperative AF, what is the next best step?

A) No change, proceed with surgery

B) Decrease lisinopril and increase metoprolol

C) Add Amiodarone

D) Add Digoxin

Question 2

Post Op

• Prevention– Beta-blockers, sotalol, amiodarone, atrial pacing

all effective– No compelling data supporting a preferred beta-

blocker.– Beta-blockers effective both pre and post op.– Digoxin, Mg, Calcium Channel Blockers thought to

be ineffective to prevent afib.

Question 3• Your 50yo patient pictured below underwent

successful ablation for moderately disabling afib 8 months ago has a recurrence of afib. They do have diabetes and hypertension that are usually well controlled except upon arising. He snores. The next step is:

• A) Repeat ablation• B) Find a more skillful Electrophysiologist• C) Pulmonary consult/sleep study• D) A visit to the Sarlacc

Obstructive Sleep Apnea and Afib

Obstructive Sleep Apnea

• Controlled studies have found an association between OSA and afib.

• There is a dose-response relationship with more severe OSA associated with higher incidence.

• Conversly 30-80% of afib patients have some form of OSA

Obstructive Sleep Apnea

• Post ablation patients have a 25% increased risk of recurrence of afib if they have untreated/undiagnosed OSA

Ng CY, Liu T, Shehata M, Stevens S, Chugh SS, Wang XMeta-analysis of obstructive sleep apnea as predictor of atrial fibrillation recurrence after catheter ablation.Am J Cardiol. 2011 Jul;108(1):47-51. Epub 2011 Apr 29.

Obstructive Sleep Apnea

• The “good” news:• CPAP Treatment of OSA reduces afib

recurrence in observational studies– 82% untreated vs 42% treated– 63% untreated vs 28% treated

• The effect of non-CPAP therapies (meds, oral appliances, surgery, trach) is not known

Heart Failure and Afib

Heart Failure

• Both afib and CHF increase in the population with age.

• It has been established that each predisposes the patient to the other condition.– HF causes atrial stretch leading to arrythmia– AF causes diminished cardiac output and may also

cause LV dysfunction

Heart Failure

Question 4

• Heart failure patients who have their rhythm normalized have lower mortality than those who remain in AF (but have controlled rates)

A) True

B) False

Heart Failure

• AF CHF 1376 patients followed for 37 mo– CV death 27% rhythm-control 25% rate-

control– death from any cause 32% 33%– stroke 3% 4%– worsening heart failure 28% 31%

• There were also no significant differences favoring either strategy in any predefined subgroup.

Roy D, Talajic M, Nattel S, Wyse DG, Dorian P, Lee KL, Bourassa MG, Arnold JM, Buxton AE, Camm AJ, Connolly SJ, Dubuc M, Ducharme A, Guerra PG, Hohnloser SH, Lambert J, Le Heuzey JY, O'Hara G, Pedersen OD, Rouleau JL, Singh BN, Stevenson LW, Stevenson WG, Thibault B, Waldo AL, Atrial Fibrillation and Congestive Heart Failure InvestigatorsRhythm control versus rate control for atrial fibrillation and heart failure.N Engl J Med. 2008;358(25):2667.

• An 80YO male with a prior history of afib is scheduled for a work in appointment due to a recurrance of arrythmia. He has been stable on amiodarone and warfarin for 3 years. He also reports wt loss, insomnia, and tremor. What lab testing do you order?

A) CBCB) Chem-7C) BNP

D) TSH

Question 5

Hyperthyroidism and Afib

Hyperthyroidism

• In a prospective study, 2007 hyperthyroid subjects ≥60 years of age who did not have AF were followed for 10 years.

• 28% hyperthyroid patients versus 11% euthroid patients developed afib

Sawin CT, Geller A, Wolf PA, Belanger AJ, Baker E, Bacharach P, Wilson PW, Benjamin EJ, D'Agostino RB Low serum thyrotropin concentrations as a risk factor for atrial fibrillation in older persons.N Engl J Med. 1994;331(19):1249.

Hyperthyroidism

• >5-fold higher likelihood for the presence of atrial fibrillation in either subclinical and overt hyperthyroidism

Auer J, Scheibner P, Mische T, Langsteger W, Eber O, Eber BSubclinical hyperthyroidism as a risk factor for atrial fibrillation. Am Heart J. 2001;142(5):838.

Hyperthyroidism

• Hyperthyroid patients experience increased:

– premature supraventricular depolarizations– atrial premature contractions (APCs– non-sustained supraventricular tachycardias– heart rate and reduced heart rate variability. – decreased parasympathetic tone.

Question 6

• The next step in the therapy is to?

A) stop amiodarone

B) arrange for cardioversion

C) both A and B

D) consult endocrinologist re methizamole

Hyperthyroidism

Hyperthyroidism

• ~55-75% of patients with atrial fibrillation due to hyperthyroidism and no other underlying cardiac valvular disease will return to sinus rhythm within three to six months after treatment of the thyrotoxic state

Question 7

• Caffeine ingestion increases risk of developing afib?

A) True

B) False

Caffeine and Afib

Caffeine

• Despite the theoretical relationship between caffeine and arrhythmogenesis, there is no evidence, in humans, that ingestion of caffeine in doses typically consumed can provoke AF or any other spontaneous arrhythmia

Mehta A, Jain AC, Mehta MC, Billie MCaffeine and cardiac arrhythmias. An experimental study in dogs with review of literature.Acta Cardiol. 1997;52(3):273.

Caffeine• 22 patients with ventricular tachycardia or fibrillation

underwent EP testing before and one hour after coffee ingestion (275 mg of caffeine). – Arrythmogenesis:• unchanged in 10 patients• increased in 6• reduced in 6

– Rhythm severity • unchanged in 17 patients• Increased in 2 patients• Reduced in 3 patients

Caffeine

• ●Meta-analysis of >100,000 individuals, caffeine exposure was not associated with an increased risk of atrial fibrillation.

• Caffeine toxicity can be associated with arrhythmic events, especially in patients with underlying cardiac disease

Caldeira D, Martins C, Alves LB, Pereira H, Ferreira JJ, Costa J Caffeine does not increase the risk of atrial fibrillation: a systematic review and meta-analysis of observational studies.

Heart. 2013 Oct;99(19):1383-9.

Question 8A frail 75YO who lives independently is newly diagnosed with afib. She has a prior history of htn and IDDM. She is mildly symptomatic. Her rate is controlled. Work up reveals mild MR, normal EF, normal TSH and no ischemia. She ambulates with a walker and owns 7 cats.

What should you do?A) Start Amiodarone and CoumadinB) Aspirin only, too high risk for full anticoagulationC) Start Coumadin or one of the new agentsD) Arrange for cardioversion

Falls and Afib

Falls• 1 of 3 adults > 65, fall each year (1/2 mention it to their

healthcare providers)

• Among older adults, falls are the leading cause of both fatal and nonfatal injuries

• In 2013, 2.5 million nonfatal falls among older adults were treated in emergency departments and more than 734,000 of these patients were hospitalized

• In 2013, the direct medical costs of falls, adjusted for inflation, were $34 billion

• 20-30% of patients who fall suffer moderate to severe injuries (lacerations, hip fractures, and head trauma)

• Leading cause of traumatic brain injuries (TBI) • 50% of fatal falls are secondary to TBI• Among older adults most fractures are caused

by falls

Falls

Question 9

• Which agent results in less intracranial hemorrhage when appropriately dosed?

A) WarfarinB) AspirinC) Risk is identical for both therapies

Falls

• BAFTA study: yearly risk of ICH– Warfarin 1.4% – Aspirin 1.6%

• Based on statistical analysis, how many times per year would a patient have to fall to make Coumadin a poor choice?

Question 10

A) 2B) 13C) 295D) Coumadin is a poor choice for any patient older than 75YO due to fall risk

Falls

• In a study using a Markov decision analytic model to determine optimal treatment in persons aged 65 years or older, which gave consideration to any potential for ICH, it was reported that persons taking warfarin would need to fall approximately 295 times within 1 year for warfarin to not be the optimal therapy.

Man-Son-Hing M., Nichol G., Lau A., Laupacis A. (1999) Choosing antithrombotic therapy for elderly persons with atrial fibrillation who are at risk for falls. Arch Intern Med 159: 677–685

Falls

• Warfarin is underprescribed – 50% of eligible patients receiving therapy.

• Falls are most often cited as the reason for not using anticoagulants in an elderly patient.

• Meta-analysis of 29 trials involving 28,044 participants shows warfarin’s benefits outweigh its risks even in patients who fall.

• Anticoagulation education has been shown to reduce the risk of bleeding.

What do the following people have in common?

Nicola Coles, Olympic Rower

Larry Bird, Boston Celtics

Birgit Fischer, German Olympian

Jerry West, NBA All-Star

Mardy Fish, American Tennis Pro

Haimar Zubeldia, Spanish Cyclist

Donald "Deke" Slayton, U.S. Astronaut

Karsten Madsen, Canadian Triathlete

Athletes and Afib

Athletes

Hours of Vigorous Exercise per week

Relative Risk of Afib

1 2 53 4

Based on:Drca N, Wolk A, Jensen-Urstad M, Larsson SAtrial fibrillation is associated with different levels of physical activity levels at different ages in men Heart doi:10.1136/heart jnl-2013-305304

Athletes

• Leisure activity (walking/cycling ) did not increase risk.

• >1 hour/day reduced risk of afib by 13%. • Was seen in almost all of the groups and was

independent of what age the activity was started.

Athletes

Endurance Sport Practice as a Risk Factor for Atrial Fibrillation and Atrial Flutter

Lluís Mont, Roberto Elosua, Josep Brugada

Europace. 2009;11(1):11-17

Orienteers (Scandinavian endurance sport) studied longitudinally for 10 years

Incidence of AFControls 0.9%Orienteers 5.3%

Athletes

• Proposed Mechanisms:– Atrial size (GIRAFA study)– Atrial fibrosis– Vagal tone– Bradycardia (increased atrial refractoriness)– Chronic inflammation– Reflux

Athletes

• Vigorous physical activity, seems to increase the risk for recurrent AF.

• Type of activity seems important• The underlying mechanisms is not yet defined,

structural atrial changes (dilatation/fibrosis) suspected

• There is a relationship between accumulated hours of practice and AF risk.

• That which improves our CAD risk increases the possibility of atrial fibrillation

OR

Conclusion

• Atrial Fibrillation may be best thought of as an indication that some other disease process is irritating the heart, rather than considering atrial fibrillation as a separate disease entity.

Valvular Heart Disease and Afib

Valvular Heart Disease

• Nearly any significant stenotic or regurgitant lesion can result in afib.

• One study of MVP with MR suggested afib developed in ~5%/year

Grigioni F, Avierinos JF, Ling LH, Scott CG, Bailey KR, Tajik AJ, Frye RL, Enriquez-Sarano Atrial fibrillation complicating the course of degenerative mitral regurgitation: determinants and long-term outcome.J Am Coll Cardiol. 2002;40(1):84.

Valvular Heart Disease

• Mitral stenosis (MS), mitral regurgitation (MR), and tricuspid regurgitation – 70%

• •MS and MR – 52%• •Isolated MS – 29%• •Isolated MR – 16%

Diker E, Aydogdu S, Ozdemir M, Kural T, Polat K, Cehreli S, Erdogan A, Göksel SMitral stenosis (MS), mitral regurgitation (MR), and tricuspid regurgitation Am J Cardiol. 1996;77(1):96.]:

AthletesSummary of the Published Studies Analyzing the Relationship Between Atrial Fibrillation and Atrial Flutter and Endurance Sport Practice

Studies Type of study Men (%) Age Type of sport(s) Cases/controlsOdds ratio (CI) for AF in athletes

Karjalainen et al.[5] Longitudinal case/control

100 47 ± 5 runners, 49 ± 5 controls

Orienteers 262/373 5.5 (1.3-24.4)

Mont et al.[6] Retrospective compared to general population

100 44 ± 13 athletes, 49 ± 11 non-athletes

Endurance sports >3 h per week

70 lone AF 61% in male athletes with lone AF

Elosua et al.[7] Retrospective case/control

100 41 ± 13 AF pat, 44±11 controls

Endurance sports: current practice and >1500 accumulated hours of practice

51/109 2.87 (1.39-7.05) adjusted for age and hypertension

Heidbuchel et al.[8] Case/control in patients undergoing flutter ablation

83 53 ± 9 sports, 60 ± 10 controls

Cycling, running, or swimming >3 h per week

31/106 1.81 (1.10-2.98)

Molina et al.[9] Longitudinal case/control

100 39 ± 9 runners, 50 ± 13 sedentary

Marathon runners 252/305 8.80 (1.26-61.29) adjusted for age and blood pressure

Baldesberger et al.[27]

Longitudinal case/control

100 67 ± 7 cyclist, 66 ± 6 golfers

Cyclists 134/62 10% AF in cyclists, 0% AF in controls

Mont et al.[10], GIRAFA study

Prospective case/control

69 48 ± 11 Endurance sports 107/107 7.31 (2.33-22.9), >550 h of accumulated heavy physical activity

Falls

• 2000 pts admitted with trauma• 278 (13.9%) had head trauma with ICH• 21 were on Warfarin• 14 injuries due to a fall• 5 bled spontaneously and then subsequently

fell

• Mortality rate ~50%

ANY QUESTIONS?