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Réduction de la Fibrillation Auriculaire en Pratique de Ville
Samer Nasr, M.D.Mount Lebanon Hospital.
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Classification Lone atrial fibrillation:
Younger than 60 years old. No clinical or echo evidence of cardiopulmonary disease. Favorable prognosis. Thromboembolism usually not an issue.
Substrate related atrial fibrillation. ETOH Hyperthyroidism HTN Surgery Metabolic disorders Cardiomyopathy MI Obesity Sleep apnea Pericarditis Valvular disease Myocarditis Heart failure PE CAD
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Substrate Related Atrial Fibrillation.
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Substrate Related Atrial Fibrillation.
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Substrate Related Atrial Fibrillation.
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AF: Treatment OptionsRhythm
normalization
- AA drugsIaIcIIINew AAd
- Cardioversion- Non AA drugs- AF Ablation
Rate normalization
- AV node blockers BB -DIGCA -…
- AV node ablation
Stroke prevention
-PharmacologicAC ++AspirinNew AT drugs
-NonpharmacologicRemoval/isolation LA appendage
Anti – coagulation
INR: 2-3
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Lone Atrial Fibrillation:Outpatient Conversion to NSR.
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Lone Atrial Fibrillation
Rate of progression to permanent atrial fibrillation.
Prognosis
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First Episode
Paroxysmal (recurrent)
Permanent
LoNE
No recurrence
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Probability of AF recurrence after the first episode
the Canadian Registry of Atrial FibrillationAm Heart J 2005;149:489- 96
757 patients
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UK Registry .BMC Cardiovascular Disorders 2005, 5:20
525 patients
Progressing to chronic AF after the first episode
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Olmsted CountyCirculation. 2007;115:3050-3056
30-Year Follow-Up
Long-term progression of paroxysmal or persistent lone AF to permanent AF
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=> the risk of progression to permanent atrial fibrillation is around 20% in young patients
=> Up to 30% of patients will not recur their AF after the first episode
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UK RegistryBMC Cardiovascular Disorders 2005, 5:20
525 patients5 y F-U
Mortality rate in paroxysmal atrial fibrillation
* Relative risk estimated by Cox regression model, including age, sex, smoking, heart failure, ischaemic heart disease, hypertension, cerebrovascular disease and diabetes.
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Olmsted CountyCirculation. 2007;115:3050-3056
Long-term observed survival in lone AF
30-Year Follow-Up
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=> Patients with lone atrial fibrillation have a normal life expectancy.
=> Comorbidities significantly modulate AF prognosis and complications: hypertension, diabetes, heart failure, and advancing age …
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Long term efficacy of
Anti-arrhythmic drugs
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Roy D, et al. New Engl J Med. 2000;342:913–920.
CTAF Study: % of Patients Remaining Free of Recurrence of AF
0.00 100 200 300 400 500 600
Days of Follow-up
Patie
nts W
ithou
t Rec
urre
nce
(%)
20
40
60
80
100
Amiodarone (n = 201)
Sotalol (n = 101)
Propafenone (n = 101)
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Adverse Effects of Oral Amiodarone
Zimetbaum P. N Engl J Med 2007;356:935-941
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Treatment of Paroxysmal Atrial Fibrillation in Outpatient Setting.
Out patient management of PAF can be performed using: Pill-in- the-pocket. Amiodarone. Dronaderone.
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Pill-in-the-pocket
1. A beta-blocker or NDHP Ca-blocker.2. Half an hour later ; if symptoms
persist: Propafenone:
▪ 600 mg if > 70kg▪ 450mg if <70 KG
Flecanide:▪ 300 mg if >70 kg.▪ 200 mg if < 70 kg.
Only once in 24 hour period.
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Pill-in-the-Pocket
268 patients presenting to ER with AF. given Flecanide or Propafenone.
▪ 58 had treatment failure or side effects; excluded▪ Out-of-Hospital self administration of Flecanide or
Propafenone studied in remaining 210. ▪ 79 percent had episodes of arrhythmias
92 % treated 36±93 minutes after sx onset Treatment succesful in 94% of episodes.
Alboni P, et al. NEJM, 2004;351:23.
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“Pill in the Pocket” Technique
154.9 1.6
01020304050
80
Paroxysms of AF Emergency visits Hospitalizations
Previous year Pill in the Pocket treatment period
P < 0.001
45.6
P < 0.001
ns59.8
54.56070
Alboni P, et al. N Engl J Med. 2004;351:2384-2391.
episodesper month
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… For additional safety
Treat the first episode inpatient with IC antiarrhythmics. Make sure QT interval stays unchanged
with therapy.
Perform exercise stress test on therapy and document QRS interval stability prior to initiating pill-in-the-pocket technique.
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Lone Atrial Fibrillation
Outpatient therapy of Lone AF can be performed safely and effectively if thorough patient selection with appropriate work up is performed.
QOL is The main goal of outpatient therapy.
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Amiodarone in Outpatient SettingDosages and precautions
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Electrophysiological Action of Amiodarone
Zimetbaum P. N Engl J Med 2007;356:935-941
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Recommendations Baseline screening studies should
include tests of liver, thyroid, and pulmonary function as well as chest radiography.
It is reasonable to initiate amiodarone therapy in the outpatient setting.
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Recommendations A slightly reduced loading dose (e.g., 600 mg
per day in one dose or divided doses for 3 to 4 weeks) is reasonable.
The patient should undergo electrocardiography weekly or should be discharged with a loop recorder to monitor heart rhythm, heart rate, and duration of the QT interval.
If conversion has not occurred by the end of the loading period, electrical cardioversion should be performed, followed by a reduction in the dose of amiodarone to 200 mg daily.
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Hohnloser. N Engl J Med 2009;360:668-78.ATHENA study
The ATHENA Trial
A placebo-controlled, double-blind, parallel arm Trial to assess the efficacy of
dronedarone 400 mg bid for the prevention of cardiovascular Hospitalization or death
from any cause in patiENts with Atrial fibrillation / atrial flutter
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Dronedarone reduces Cardiovascular Death
Hohnloser. N Engl J Med 2009;360:668-78.ATHENA study
0.0
2.5
5.0
7.5
230122902274
22502240
16291593
636 615
7 4
2327
Placebo
PlaceboDronedarone
MonthsPatients at risk
HR=0.71P=0.034
Dronedarone
0 6 12 18 24 30
Cum
mul
ativ
e In
cide
nce
(%)
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Dronedarone reduces the incidence of cardiovascular hospitalization or death
Hohnloser. N Engl J Med 2009;360:668-78.ATHENA study
0
10
20
30
40
50
230118581963
16251776
10721177
385 403
3 2
2327
Placebo
PlaceboDronedarone
MonthsPatients at risk
Dronedarone
HR=0.76P<0.001
0 6 12 18 24 30
Cum
mul
ativ
e In
cide
nce
(%)
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Dronaderone vs Amiodarone Meta-analysis on Dronaderone vs Amiodarone:
From ANDROMEDA to. DIONYSOS. Dronaderone less effective than amiodarone for
atrial fibrillation with an odds ratio of 0.5 . ▪ Less Side Effects.▪ Less efficacy.
Dronaderone trades efficacy for safety.
Piccini et al, J. Am Coll Cardiol. 2009: 54:1089-1095
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Conclusion:
Lone atrial fibrillation: a benign disease.
Strict rules should apply to outpatient therapy.
Careful initial screening for underlying heart disease is imperative.
Frequent reevaluation of the substrate is a must to ensure that organic heart disease has not occurred with time.