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Pharmacologic and Non-Pharmacologic Treatment of Atrial Fibrillation
October 2019
Otto Costantini MD
Director, Electrophysiology Section
Director, Medical Education and Clinical Research
Summa Health Heart and Vascular Center
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Overview
• Scope of the Problem
• Pharmacologic Treatment
o Rhythm vs. Rate control
o Anticoagulation
•Non-pharmacologic Treatment o Pulmonary Vein Isolation (i.e. RFA)
o AVN Ablation/Pacing
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The Electrophysiologist World
Arrhythmia Treatment Cure •AVNRT RFA 99% •AVRT/WPW RFA 95% •Atrial Flutter RFA 90% •Atrial Tachycardia RFA 85%
•Atrial Fibrillation Meds vs RFA 60-80%
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AF
Po
pu
lati
on
(x 1
000)
Age (years)
Po
pu
lati
on
(x
10
00
)
Atrial Fibrillation
2.3 million
Feinberg et al. Arch Intern Med. 1995;155:471.
500
400
300
200
100
0
30,000
20,000
10,000
0
US population
AF population
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Summa Health Sample Preso 5 06.01.2016
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Atrial Fibrillation and Death in the Framingham Heart Study
Circ. 1998;98:946-52
RR 1.3-1.9
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Classification of Atrial Fibrillation Classification Description
Paroxysmal Terminates within 7 days of onset
Persistent Continuous for more than 7 days
Longstanding Persistent Persists greater than 1 year
Permanent All attempts to restore sinus rhythm have been abandoned
Lone AF Occurs in patients less than 60 years of age who do not have HTN or evidence of structural heart disease
-Some patients with paroxysmal AF can have episodes that persist, the predominant form determines how it is characterized -cardioversion and antiarrhythmic drug therapy should not alter the classification
8
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Co-morbidities
•Diabetes
•Hypertension
• Sleep Apnea
•Alcohol Intake
• Hyperthyrodism
Summa Health Sample Preso 9 06.01.2016
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Pharmacologic Considerations
• Rate vs. rhythm control
•No matter which you decide on, you still have to worry about anticoagulation
http://www.aafp.org/afp/2011/0101/afp20110101p61-f3.jpg
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Anticoagulation
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Anticoagulation
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Rate Vs. Rhythm Control
Trial N F/U Endpoint P Value
PIAF 252 1 y Symptoms 0.3
STAF 200 1.8y TM/CVA/CPR NS
RACE 522 2.3y TM/CHF 0.11
AFFIRM 4060 3.5y Total Mortality 0.08
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The AFFIRM Trial
•Atrial Fibrillation Follow-up Investigation in Rhythm Management Trial •Age greater than 65 years OR •Age less than 65 years plus a risk factor for stroke: •Hypertension/diabetes • CHF or LVEF < 0.40, prior CVA/TIA • LAE > 50 mm
• 6 hrs of AF in 1 or more episodes in 6 months •Duration <6 months or SR for > 24 hrs
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Patient Refusal: 67%
MD Refusal: 31%
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0.08
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Rate Control Strategy
•Consider in: o Asymptomatic patients o Longstanding persistent o High likelihood of recurrence
•Avoid in: oYounger patients ??? oFirst episode ??? oSymptomatic patients
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Pharmacologic Agents for Rate Control
• Calcium Channel Blockers oDiltiazem, Verapamil.
• Slow Sinus Node and AV Node function. Should not be used in Systolic HF
• Beta Blockers oPropranolol (nonselective blocker) / Metoprolol, Atenolol (selective cardio-inhibitory)
• Slow Sinus Node and AV node function.
• Preferred in systolic HF and/or concomitant CAD
•Digoxin. o inhibition of Na-K ATPase and Parasympathomimetic actions oWeak AV nodal blocking agent!
•
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Why Sinus Rhythm?
• Sinus rhythm is the best rate control. o Not too fast o Usually not too slow (Be careful in the elderly with sinus node dysfunction) o Appropriate rates with exercise. •Atrial systole improves cardiac output o Patients with systolic dysfunction need their atrial kick • Regularity (not just VR) improves cardiac output and symptoms
• Effects of AF on LV function
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Exercise Capacity
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LV Ejection Fraction
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The problem: Antiarrhythmic Drugs Effectiveness
50 49
25
49
30
37
61
28
0
10
20
30
40
50
60
70
Sinus Rhythm
Placebo
Quinidine
Norpace
Procainamide
Flecainide
Propafenone
Sotalol
Amiodarone
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The problem: Safety: Pro- Arrhythmias and Extra-Cardiac Side Effects
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Who is this? 1946-???
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Miles Vaughan Williams 1918-2016
27
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Circa 1975
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The Action Potential
29
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The Action Potential and The ECG
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Class 1 Drugs and the ECG
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Class 1 Drugs- Na Channel Blockers
32
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Flecainide (Tambocor) - 1C • Prolongs QRS & slows conduction in the atrium • The good news - effective in preventing AFib • The bad news – increased mortality in post MI patients • Therefore, contraindicated in pts with CAD • Can speed up conduction in the AV node •Must use AV Nodal Blocker with it! • Twice-a-day (100 - 300 mg/day)
• Renal Excretion
•Most common side-effects oheadache, dizziness, asthenia, blurred vision, hair loss.
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Propafenone (Rythmol) - 1C
• Similar story to flecainide
• Three times a day (300 -900 mg/d).
•Weak -blockade
• Liver metabolism
•Neurologic symptoms, metallic taste, GI disturbances
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Class 3- K Channel Blockers
35
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Sotalol (BetaPace) – Class 3
•No increase in QRS duration or slowing of conduction • Racemic mixture (D-L Sotalol): type III effect and -blockade •Dose-related Torsades de Pointes oHistory of sustained VT or VF oFemale gender oHistory of CHF oDose greater than 320 mg/day. • -blocker effects predominate at lower doses, and type III effects at higher
doses • Less effective at conversion acutely to sinus • Renal excretion
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Dofetilide (Tikosyn) – Class 3
• Selective IKr blocker
•Approved for AFib
• Renal excretion
• Few non-cardiac side-effects
• Risk of Torsades de Pointes is high
• Safe in patients with structural heart disease including low EF (DIAMOND-HF)
•Multiple restrictions may be a factor in safety
• 58% suppression of AF in SAFIRE-D
• Reverse Use Dependance
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The Canadian Trial of Atrial Fibrillation
NEJM 2000 342:913-920
SAFE-T trial
NEJM 2005
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Dofetilide
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Dofetilide in HF - DIAMOND CHF
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Pro Arrhythmia: Dofetilide
X 10 minutes
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Amiodarone – Class 1,2,3,4
• Blocks everything- Uniformly slows conduction everywhere • Less frequent pro-arrhythmia-mainly bradycardia • Zillions of active metabolites; poor bio-availability, onset of action is slow,
drug accumulates in adipose, half-life months • Liver metabolism •Doesn’t increase risk of SCD •Most effective drug in AF
•Decreases ICD shocks
•Non-cardiac side-effects
oliver, lung, thyroid, CNS, photosensitivity
• Interacts with warfarin and digoxin.
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Dronedarone (MULTAQ) – Class 3
• Similar to Amiodarone, but lacks iodine moiety oLacks end-organ side effects
o Increases serum Cr, but the GFR is unchanged
• Better than placebo in SR maintenance
• 1/3 the potency of Amiodarone
•Avoid in CHF (EF< 40%) o 4.3% increase in absolute risk of death
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Dronedarone (Multaq): How good?
• Contraindicated in patients with HF
• The hope: amiodarone without the side effects
• The reality: amiodarone lite
J Cardiovasc Electrophysiol, Vol. 21, pp. 597-605, June 2010)
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Guidelines for Management of Atrial Fibrillation: Strategies for Rhythm Control
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• Most patients do not need to “go to the ED”
• If the rate is very fast and they are having CP or they are in HF… sure!
• Otherwise:
• If CHADS VASC score is >1: Anti Coagulate
• If rate is > 100: rate control
• Refer to cardiology
• … or now you can start an antiarrhythmic drug
What to do when patients present to the office in AFib
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1. Class 1C Drugs can be started as an outpatient at low doses in patients with structurally normal hearts
2. All patients started on Class 1C drugs should get an exercise stress test to observe for pro-arrhythmia and to rule out significant coronary artery disease.
3. Patients started on Dofetilide need to be started as in-patients to observe for QTc prolongation.
4. Sotalol has been started as an outpatient in small studies. Controversial whether it should be.
5. Amio has a lower risk of pro-arrhythmia
Take Home Points:
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6. Long Term Follow Up of Amiodarone patients should include TSH routinely. PFTs if symptoms develop
7. Watch for Sinus Node Dysfunction. Elderly Patients will get more bradycardic with all AA drugs other than dofetilide
8. Watch for Renal Failure. Most of these drugs are contraindicated or need to have dose adjustments
Check BMP ~every 6 months
Take Home Points:
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Summa Health Sample Preso 49 06.01.2016
Strategies for Rhythm Control in Patients with Paroxysmal and Persistent AF
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Current Guidelines
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• Main goal of catheter ablation for treatment of AF is to isolate the Pulmonary Veins from the body of the Left Atrium
• Approach is based on the finding that the electrical impulses that trigger AF originate at the connection of the veins with LA
Summa Health Sample Preso 51 06.01.2016
History of Catheter Ablation
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History of Catheter Ablation
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Summa Health Sample Preso 53 06.01.2016
Proposals concerning the mechanisms of AF
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Mechanism of Atrial Fibrillation
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Summa Health Sample Preso 55 06.01.2016
Common lesion sets employed in AF Ablation
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Pulmonary Vein Isolation
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3-D Navigation Systems
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• Determine efficacy of catheter ablation compared to AAD in treating symptomatic AF
• 159 patients who did not respond to at least 1 antiarrhythmic drug and who experienced at least 3 AF episodes within 6 months
• 103 patients underwent ablation and 56 underwent AAD (Amiodarone not allowed)
THERMOCOOL-AF Trial
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THERMOCOOL-AF
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• Most common method is radiofrequency current applied in a point by point mode which leads to cellular necrosis by tissue heating
• Requires only limited use of Fluoro because guidance is through the use of an Electro-anatomical mapping system
• Requires extensive training
• Restricted to specialized centers and has limited the availability
Radio-Frequency Ablation vs. Cryo-Ablation
• Second most common method is the use of cryogenic energy applied with a balloon in a single step mode which leads to necrosis by freezing
• Requires more extensive fluoro guidance to position the balloon catheter at the pulmonary veins
• Creates a circular lesion around each vein in a simple manner
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• Study designed to compare the performance of well established but complex RF approach with the simpler but unproven cryo balloon approach.
• Multicenter, Randomized, Non-Inferiority trial
• Included patient with symptomatic PAFib that was refractory to AAD
• Primary Endpoint – Time to AF recurrence/Prescription of AAD/Repeat Ablation
FIRE AND ICE Trial
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62
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FIRE AND ICE Trial
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• Multicenter, Prospective, Randomized Trial designed to test the hypothesis that ablative therapy for AF is more effective than AAD in a population of symptomatic AF patients followed for 3 years
• Primary end point = composite of death, stroke, bleeding, or cardiac arrest
• Secondary end points = All cause mortality, total mortality/hospitalization, AF recurrence
CABANA Trial
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CABANA Trial
• Baseline Characteristics Median Age 67
37% Women
10% Minorities
43% had Paroxysmal AF
80% HTN
25% Diabetes
19% CAD
10% Prior CVA
15% CHF
57% CHADS2VASC greater than 2
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CABANA Trial
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CABANA Trial
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• The trial included 397 patients with symptomatic paroxysmal or persistent AFib and a LVEF of ≤35 percent who were randomized to receive either RF ablation or conventional AAD.
• Largest trial to utilize catheter ablation in HF patients
• Median F/U of 40 months
• Primary outcome – composite of death from any cause or worsening HF
• Secondary outcome – death from any cause, HF hospitalization, CVA, Cardiovascular death
CASTLE-AF Trial
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CASTLE-AF Trial
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Monitoring
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Conclusions
•Anticoagulation for Atrial Fibrillation should be guided by the CHA2DS2VASC Score.
• Rate vs. Rhythm control should be guided by patient’s symptomatology and preference
• Rhythm Control can be achieved with anti-arrhythmic drugs at the expense of long term side effects and pro-arrhythmia.
•Ablation of Atrial Fibrillation is an acceptable method for rhythm control, and the only hope for a cure. Recurrences are frequent.