rhythm management. 2 defining atrial fibrillation a supraventricular tachycardia characterized by...

Rhythm Management

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2

Defining Atrial Fibrillation

• A supraventricular tachycardia characterized by uncoordinated atrial activation with consequent deterioration of atrial mechanical function

• Characterized by replacement of consistent P waves with rapid oscillation of fibrillatory waves, varying in amplitude, shape, and timing

• Associated with an irregular and frequently rapid ventricular response (with intact AV conduction)

• For management purposes, atrial flutter should be treated as AF

Fuster et al. J Am Coll Cardiol. 2006;48:854-906.

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Management of Patient With AF

Initial Presentation With AF

Initial Presentation With AF

Hemodynamically Stable

Hemodynamically Stable

Hemodynamically Unstable

Hemodynamically Unstable


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Classification of AFACC/AHA/ESC Guidelines


Persistent(Not self-terminating)

Persistent(Not self-terminating)

Paroxysmal(Self-terminating)

Paroxysmal(Self-terminating)

First Detected

First Detected

PermanentPermanent

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Pharmacologic Management of Patients With Newly Discovered AFACC/AHA/ESC Guidelines


Newly Discovered AFNewly Discovered AFNewly Discovered AFNewly Discovered AF

ParoxysmalParoxysmalParoxysmalParoxysmal

No therapy needed, No therapy needed, unless severe unless severe

symptoms symptoms (eg, hypotension, HF,(eg, hypotension, HF,

angina pectoris)angina pectoris)




PersistentPersistentPersistentPersistent

Accept permanent AFAccept permanent AFAccept permanent AFAccept permanent AF

AnticoagulationAnticoagulationand rate control,and rate control,

as neededas needed


as neededas needed

Rate control andRate control andanticoagulation,anticoagulation,

as neededas needed


as neededas needed

Consider antiarrhythmicConsider antiarrhythmicdrug therapydrug therapy


Long-term drugLong-term drugprevention unnecessaryprevention unnecessary


Anticoagulation,Anticoagulation,

as neededas needed


as neededas neededCardioversionCardioversionCardioversionCardioversion

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Management of Stable Patients With AF

• Control heart rate

• Determine duration of AF

• Anticoagulation as appropriate

• Assess for comorbidities and contributing/reversible factors

• Decide rate or rhythm strategy

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Pharmacologic Management of Patients With Newly Discovered AFRecurrent Paroxysmal AF













as neededas needed


as neededas needed


as neededas needed


as neededas needed






as neededas needed



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Anatomic and Electrophysiologic Substrates Promoting AF Initiation and Maintenance

Substrates

Diseases Anatomic Cellular Electrophysiologic

Substrate pathways during sinus rhythm (remodeling related to stretch and dilatation). Main pathways involve the RAAS, TGF-Beta, and CTGF

Htn Atrial dilatation Myolysis Conduction Abnormalities

HF PV dilatation Apoptosis, necrosis

ERP dispersion

CAD Fibrosis Channel expression change

Ectopic activity

Valvular disease


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Anatomic and Electrophysiologic Substrates Promoting AF Initiation and Maintenance

Substrates

Diseases Anatomic Cellular Electrophysiologic

Substrate develops due to tachycardia (tachycardia-related modeling, downregulation of calcium channel, and calcium handling).

Focal AF None or None or Ectopic activity

A Flutter Atrial dilatation Ca++ channel downregulation

Microreentry

PV dilatation Myolysis Short ERP

Large PV sleeves Connexin downregulation ERP dispersion

Decrease Contractility Adrenergic supersensitivity

Slowed conduction

Fibrosis Changed sympathetic innervation


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Etiologies and Factors Predisposing Patients to AF

Endocrine disorders

Hyperthyroidism

Pheochromocytoma

Changes in autonomic tone

Increased parasympathetic activity

Increased sympathetic activity

Primary or metastatic disease

Postoperative

Cardiac, pulmonary, or esophageal

Congenital heart disease

Neurogenic

Subarachnoid hemorrhage

Nonhemorrhagic, major stroke

Idiopathic (lone AF)

Familial AF

Electrophysiologic abnormalities Enhanced automaticity (focal AF)

Conduction abnormality (reentry)

Atrial pressure elevation Mitral or tricuspid valve disease

Myocardial disease (1o or 2o, with systolic or diastolic dysfunction)

Aortic valve disease with LVH

Systemic or pulmonary hypertension

Intracardiac tumors or thrombi

Atrial ischemia (CAD)

Inflammatory/infiltrative atrial disease Pericarditis, amyloidosis, myocarditis

Age-induced atrial fibrotic changes

Drugs Alcohol

Caffeine


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Mechanisms of AF

Focal ActivationFocal Activation Multiple WaveletsMultiple Wavelets

RARALALA

PVsPVs

IVCIVC

SVCSVCRARALALA

PVsPVs

IVCIVC

SVCSVC


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Anatomy of Pulmonary Veins

Extension of muscular fibers into pulmonary vein (PV)

Ganglia noted in yellow

Large and small reentrant wavelets that play a role in initiating andsustaining AF

Common locations of PV (purple) and common sites of origin of non-PVtriggers (black)

Composite of anatomic and arrhythmic mechanisms of AF

Calkins et al. Heart Rhythm. 2007;4:1-46.

LSPV

LIPV

RSPV

IVC

RIPV

SVC

LSPV

LIPV

RSPV

IVC

SVC

LSPV

LIPV

RSPV

IVC

RIPV

SVC

LSPV

LIPV

RSPV

IVC

RIPV

SVC

RIPV

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Mechanisms of AF: Triggers for Induction of AF

Triggers that induce AF includeSympathetic or parasympathetic stimulation

Bradycardias or atrial tachycardias or atrial premature contractions

Acute atrial stretch

Ectopic foci

• Pulmonary vein, RA, SVC, coronary sinus, other areas

Reentrant wavelets if wavelengths are short

• Depressed conduction velocity

• Unstable reentrant circuit of short cycling

• Stable reentrant circuit of short cycling

Allessie et al. Circulation. 2001;103:769-777.

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Allessie et al. Circulation. 2001;103:769-777.

Mechanisms of AF: Perpetuation

Substrate that sustains AFPersistence of triggers

Persistence of atrial dilation

Persistence of shortened AERP

Increased dispersion in AERP

Inhomogeneous dispersion of conduction abnormalities

Disorganization and fragmentation of gap junctions

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Perpetuation of AF: Electrophysiologic Mechanisms

Wijffels et al. Circulation. 1995;92:1954-1968.

ControlControl

After After 24 hours24 hours

After After 2 weeks2 weeks

BurstBurstpacingpacing AFAF Sinus rhythmSinus rhythm Duration ofDuration of

fibrillationfibrillation

5 seconds5 seconds

20 seconds20 seconds

>24 hours>24 hours

AFAF

Sustained AFSustained AF

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Pharmacologic Management of Patients With Newly Discovered AFRate Control vs Rhythm control













as neededas needed


as neededas needed


as neededas needed


as neededas needed






as neededas needed



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Rate and Rhythm Control Definitions

•Rate control• Ventricular rate is controlled both at rest and with exertion

• No commitment to maintaining SR

•Rhythm control• Attempts restoration and maintenance of SR

• Rate control required as needed

•Can switch from rhythm control to rate control, but harder to switch from rate control to rhythm control if AF has been persistent for a long period of time

•DO NOT FORGET ANTICOAGULATION AS NEEDED for either strategy


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What Is Adequate Rate Control?

• Adequate rate control is critical to avoid tachycardia-mediated cardiomyopathy

• 60-80 beats per minute at rest AND

• 90-115 beats per minute with exertion

• Criteria vary with age

• May be evaluated using 24-hour Holter recording


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Achieving Rate Control Class/Recommendations

AcutelyIV administration of -blockers (esmolol, metropolol, or propranolol) or nondihydropyridine calcium channel blocker (verapamil, diltiazem)

IV administration of digoxin or amiodarone in patients with HF (only in the absence of an accessory pathway)

Long-termMeasurement of heart rate at rest and with exertion

Beta blockers or nondihydropyridine calcium channel blocker

Digoxin only in patients with HF, LV dysfunction, or sedentary individuals


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Agents for Heart Rate Control Acute Setting

Drug Loading Dose Onset Maintenance Dose Major Side Effects

Heart rate control in patients without accessory pathway

Esmolol 500 mcg/kg IV over 1 min

5 min 60 to 200 mcg/kg/m IV

↓ BP, HB, ↓ HR,asthma, HF

Metoprolol 2.5 to 5 mg IV bolus over 2 min; up to 3

doses

5 min NA ↓ BP, HB, ↓ HR,asthma, HF

Propranolol 0.15 mg/kg IV 5 min NA ↓ BP, HB, ↓ HR,asthma, HF

Diltiazem 0.25 mg/kg IVover 2 min

2 to 7 min

5 to 15 mg/h IV ↓ BP, HB, HF

Verapamil 0.75 to 0.15 mg/kg IV over 2 min

3 to 5 min

NA ↓ BP, HB, HF


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Agents for Heart Rate Control: Acute Setting

Drug Loading Dose OnsetMaintenance

Dose Major Side Effects

Heart rate control in patients with accessory pathway

Amiodarone 150 mg over 10 min

Days 0.5 to1 mg/min IV

↓ BP, HB, pulmonary toxicity, skin discoloration, hypo- and

hyperthyroidism, corneal deposits, optic neuropathy, warfarin

interaction, sinus bradycardia

Heart rate control in patients with HF and without accessory pathway

Digoxin 0.25 mg IV each 2 h, up to 1.5

mg

60 min 0.125 to 0.375 mg daily IV

or PO

Digitalis toxicity,HB, ↓ HR

Amiodarone 150 mg over 10 min

Days 0.5 to 1 mg/min IV

As above


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Agents for Heart Rate Control: Nonacute and Chronic Maintenance

Drug OnsetLoading and Maintenance


Heart rate control

Metoprolol 4 to 6 h 25 to 100 mg bid, PO ↓ BP, HB, ↓ HR,asthma, HF

Propranolol 60 to 90 min 80 to 240 mg daily individed doses, PO

↓ BP, HB, ↓ HR,asthma, HF

Diltiazem 2 to 4 h 120 to 360 mg daily in divided doses; slow release available,

orally

↓ BP, HB, HF,digoxin interaction

Verapamil 1 to 2 h 120 to 360 mg daily in divided doses; slow release available, PO

↓ BP, HB, HF,digoxin interaction


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Agents for Heart Rate Control: Nonacute and Chronic Maintenance

Drug Loading Dose OnsetMaintenance


Heart rate control in patients with HF and without accessory pathway

Digoxin 0.5 mgPO daily

2days

0.125 to 0.375 mg qd, PO

Digitalis toxicity, HB, ↓ HR

Amiodarone 800 mg qd for 1 wk, PO

600 mg qd for 1 wk, PO

400 mg qd for 4 to 6 wk, PO

1 to 3 wk

200 mg qd, PO ↓ BP, HB, pulmonary toxicity, skin discoloration, hypo- and

hyperthyroidism, corneal deposits, optic neuropathy, warfarin

interaction, sinus bradycardia


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Pharmacologic Management of Patients With Newly Discovered AFACC/AHA/ESC Guidelines













as neededas needed


as neededas needed


as neededas needed


as neededas needed






as neededas needed



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Clinical Considerations for Management Strategy

• Duration and patterns of AF

• Type and severity of symptoms

• Associated cardiovascular disease

• Potential for changes in cardiac function over time


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Rhythm vs Rate Control in AF Evidence Base

AFFIRM Atrial Fibrillation Follow-up Investigation of Rhythm Management

RACE RAte Control versus Electrical Cardioversion for Persistent Atrial Fibrillation

PIAF Pharmacological Intervention in Atrial Fibrillation (pilot)

STAF STrategies in Atrial Fibrillation (pilot)

HOT CAFÉ HOw to Treat Chronic Atrial Fibrillation

5 prospective, controlled, randomized trials comparing 2 different treatment strategies


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Rhythm vs Rate Control in AF Evidence Base

Trial Follow-up (y)Age, y

(mean SD) Patients in SRa

AFFIRM (2002) 3.5 70 9 35% vs 63% (at 5 y)

RACE (2002) 2.3 68 9 10% vs 39% (at 2.3 y)

PIAF (2000) 1.0 61 10 10% vs 56% (at 1 y)

STAF (2003) 1.6 66 8 11% vs 26% (at 2 y)

HOT CAFÉ (2004) 1.7 61 11 NR vs 64%

aComparison between rate and rhythm control group.Fuster et al. J Am Coll Cardiol. 2006;48:854-906.

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02468

101214161820 Rate Rhythm

Rhythm vs Rate Control in AF Evidence Base (cont'd)


Per

cen

t

Stroke Death

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The AFFIRM Investigators. N Engl J Med. 2002;347:1825-1833; Waldo. Am J Cardiol. 1999;84:698-700.

Patient Characteristics in AFFIRM

• Long-term treatment of chronic and paroxysmal AF

• Patients 65 years of age or other risk factor for stroke with

• AF 6 hours in past 6 months• Not continuous AF for 6 months1 episode documented by ECG in past 12 weeks1 risk factor for stroke (age 65 years)• AF likely to be recurrent• Able to participate in trials of ≥2 drugs in both strategies

• Randomized to rate vs rhythm control• Patients required to be able to tolerate AF; therefore, patients were a

relatively asymptomatic group

• Both groups anticoagulated

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Patient Characteristics in RACE

• Inclusion criteria• Recurrent, persistent atrial fibrillation or flutter

• No contraindication to anticoagulation

• Undergone 1-2 cardioversions within 2 years prior to enrollment

• Exclusion criteria• Duration of arrhythmia >1 year

• NYHA functional class IV CHF

• Current or previous treatment with amiodarone or pacemaker

Van Gelder et al. N Engl J Med. 2002;347:1834-1840.

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Primary End Point All-Cause Mortality in AFFIRM

Cu

mu

lati

ve M

ort

alit

y (%

)C

um

ula

tive

Mo

rtal

ity

(%)

Time (years)

3030

2525

2020

1515

1010

55

00

00 11 22 33 44 55

Rhythm ControlRhythm Control

Rate ControlRate Control

PP=.058=.058

Wyse. Presented at: American College of Cardiology 51st Annual Meeting; March 17-20, 2002; Atlanta, GA.

Rhythm N:Rhythm N: 20332033 19321932 18071807 13161316 780780 255255Rate N:Rate N: 20272027 19251925 18251825 13281328 774774 236236

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00 11 22 33 44 55

Cumulative Cardiac Mortality in AFFIRM

N, Events (%)Rate 2027, 0 (100) 1926, 42 (2) 1827, 69 (3) 1329, 92 (5) 774, 115 (7) 236, 130 (10) 1, 130 (10)Rhythm 2033, 0 (100) 1932, 37 (2) 1807, 70 (4) 1316, 94 (5) 780, 116 (7) 255, 129 (9) 1, 129 (9)

Steinberg et al. Circulation. 2004;109:1973-1980.

Log-rank statistic=0Log-rank statistic=0PP=.9517=.9517

3030

2525

2020

1515

1010

55

00

Dea

th (

%)

Dea

th (

%)



Time (years)

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Cumulative Noncardiovascular Mortality in AFFIRM

Steinberg et al. Circulation. 2004;109:1973-1980.

11 22 33 44 55

Time (years)

00

3030

2525

2020

1515

1010

55

00

Dea

th (

%)

Dea

th (

%)



Log-rank statistic=11.2Log-rank statistic=11.2PP=.0008=.0008

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AFFIRM Results Post-hoc Analysis

The benefits of sinus rhythm areoffset by the toxicity of AADs used in AFFIRM

The benefits of sinus rhythm areoffset by the toxicity of AADs used in AFFIRM

Corley et al. Circulation. 2004;109:1509-1513.

AAD use

Digoxin use

Warfarin use

Sinus rhythm

Time dependent

Covariate

.0005.0005

.0007.0007

<.0001<.0001

<.0001<.0001

PP Value Value

0 0.5 1 1.5 2 2.5

HR 99% CIHR 99% CI

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Quality of Life in AF RACE Study

5463

47

8174 77

71

5962 64 6773

7781 84

65

0

20

40

60

80

100Control subjects (n=172) RACE subjects (n=352)

Hagens et al. J Am Coll Cardiol. 2004;43:241-247.

Sco

re (

mea

n)

on

SF

-36

Sca

les

General Health

Physical Functioning

Role Physical

Bodily Pain

Mental Health

Social Functioning

Role EmotionalVitality

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A4 Study Results: Quality of Life

0 20 40 60 80 100

AAD Group(n=59)

Ablation Group(n=53)

Physical function

Social function

Mental health

Physical component

Mental componentP=.0106

P=.0174

P=.0018

P=.0024

P=.0012

Jaïs et al. Presented at: Heart Rhythm Society 2006 Annual Scientific Sessions; May 17-20, 2006; Boston, MA.

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0

5

10

15

20

25

Frequency Severity

AF (n=152) PTCA (n=69) Healthy (n=47)

a

b

aP<.001 compared with AF patients; bP<.01 compared with AF patients.Dorian et al. J Am Coll Cardiol. 2000;36:1303-1309.

Symptoms in AF

a

b

Qu

alit

y o

f L

ife

Sco

re

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Incr

ease

in

Du

rati

on

(se

con

ds)

Sinus Rhythm Atrial Fibrillation

Exercise Duration: AF vs SRSAFE-T Trial

Singh et al. J Am Coll Cardiol. 2006;48:721-730.

P=.01P=.02

0

20

40

60

80

100

8 Weeks 1 Year

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Rate vs Rhythm Control ACC/AHA/ESC

“Before choosing rate control as a long-term strategy, the clinician should consider how permanent AF is likely to affect the patient in the future. RACE…and AFFIRM…do not necessarily apply to younger patients without heart disease or to patients whose dependency upon sinus rhythm is likely to change appreciably over time. This makes it important to ensure that a window of opportunity to maintain sinus rhythm is not overlooked early in the course of management of a patient with atrial fibrillation.”


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AF in Patients With HF

HF may develop or deteriorate with AFProgression of underlying cardiac disease

Uncontrolled heart rate

Antiarrhythmic drug toxicity

AF may exacerbate HF symptoms due toLoss of atrial “kick”

Rapid heart rate

Patients in AFFIRM did not develop or deteriorate differently in rate vs rhythm arms


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Impact of Rhythm Control on HF

Study Key Findings

PIAF Rhythm control resulted in better exercise capacity when compared with rate control

CHF-STAT Patients with AF who converted to normal sinus rhythm on amiodarone had a lower mortality compared with those who did not

Catheter ablation for atrial fibrillation in congestive heart failure

Restoration and maintenance of sinus rhythm using catheter ablation improved cardiac function, symptoms, exercise capacity, and quality of life in patients with CHF and AF

PABA-CHF trial AF ablation was superior to AV nodal ablation with biventricular pacing in improving ejection fraction, 6-minute walk distance and quality of life in a cohort of patients with CHF

CHF=congestive heart failure.Akoum and Hamdan. Current Heart Failure Reports. 2007;4:78-83.

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Hospitalization for Worsening HFDIAMOND CHF

Dofetilide Events=229Dofetilide Events=229n=762n=762

Placebo Events=290Placebo Events=290n=756n=756

HR=0.75HR=0.7595% CI, 0.63-0.8995% CI, 0.63-0.89PP<.001<.001

Pro

bab

ilit

y o

f S

urv

ival

Pro

bab

ilit

y o

f S

urv

ival

Time (months)Time (months)

0.80.8

0.60.6

0.20.2

0.00.0

1.01.0

0.40.4

00 1212 2424

Torp-Pedersen et al. N Engl J Med. 1999;341:857-865.

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0 1 3 6 12

P.001

P.001P.001 P.001

45

0

25

30

35

40

50

55

60

65

70

LV Function Postablation in HF

Hsu et al. N Engl J Med. 2004;351:2373-2383. Month

LV

Eje

ctio

n F

ract

ion

(%

)

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AF-CHF Trial

• Prospective, open-label, multicenter trial

• Inclusion criteria–Symptomatic (NYHA class 2-4) with LVEF 35%

–Asymptomatic with prior hospitalization for CHF or LVEF 25%

–History of significant AF

–1 episode >6-hour duration within past 6 months or

–1 episode of shorter duration but with prior electrical cardioversion

• 1376 patients randomly allocated to rhythm or rate control

• 123 sites in North America, South America, and Europe

• Minimum follow-up 2 years

• Optimal heart failure management with ACE inhibitors, -blockers, and anticoagulation therapy for both groups

Roy. Presented at: American Heart Association 2007 Scientific Sessions; November 2007; Orlando, FL.

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AF-CHF Trial: Methods and Patients

• >66% had persistent AF

• >50% previously hospitalized for AF or CHF

• Cardioversion in rhythm-control group• Initial attempt with antiarrhythmic therapy

• Electrical cardioversion within 6 weeks of randomization for those not converting on antiarrhythmic drugs

» Amiodarone initial drug of choice» Sotalol and dofetilide used in select cases » Second cardioversion within 3 months if necessary» Patients refractory to antiarrhythmic drug therapy may receive additional

nonpharmacologic therapies (eg, catheter ablation)

• Rate control• Titrated doses of -blockers, digitalis, or both

• Pacemaker and AV-node ablation as needed


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AF-CHF Trial: Results

• No difference in primary end point of CV death• 182 (26.7%) rhythm control vs 175 (25.2%) rate control (HR 1.058, P=.59)

• No difference in prespecified secondary end points• Total mortality, worsening CHF, and stroke

• Composite of CV death, worsening CHF, and stroke

• CV mortality

• 21% crossover from rhythm to rate control• Primarily due to inability to maintain SR

• 10% crossover from rate to rhythm control• Primarily due to worsening HF

• Higher hospitalization rate in rhythm control (46% vs 39% at 1 year; P=.0063)• Mainly due to hospitalization for AF and bradyarrhythmias (8.5% vs 4.9%; P=.0074)

• Higher rate of cardioversions in rhythm control (39% vs 8%)


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AF-CHF Trial of Rate vs Rhythm

0

10

20

30

40

50

CV Death Hospitalization Rate Bradyarrhythmias

Rate

Rhythm

Roy. Presented at: American Heart Association 2007 Scientific Sessions; November 2007; Orlando, Florida.

Per

cen

tP

erce

nt

Also, no differences noted in secondary end points of total mortality, worsening CHF, and stroke

Also, no differences noted in secondary end points of total mortality, worsening CHF, and stroke

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AF-CHF Trial: Implications

• In stable patients, no advantage to rhythm control for mortality or secondary end points

• QoL results pending

• Cannot be extrapolated to patients with clear-cut deterioration in clinical status at onset of AF

• Decision for rate versus rhythm strategy must besymptom-driven


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Symptom-driven decisions are recommendedSymptom-driven decisions are recommendedCaveat: symptoms may be subtle or difficult to elicit,Caveat: symptoms may be subtle or difficult to elicit,

so question patients carefullyso question patients carefully

Rate vs Rhythm Control

Current randomized studies do not demonstrate mortality differences in rate vs rhythm treatment approaches

Patients randomized to these studies were

older, relatively asymptomatic, and

considered appropriate for either strategy

Benefits of SR may be offset by AAD

toxicity

QoL studies have indicated better results with SR

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Pharmacologic Management of Patients With Newly Discovered AFCardioversion













as neededas needed


as neededas needed


as neededas needed


as neededas needed






as neededas needed



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Druga

Route of Administration Dosageb Potential Adverse Effects

Amiodarone Oral Inpatient: 1.2 to 1.8 g qd in divided doseuntil 10 g total, then 200 to 400 mg qd

maintenance or 30 mg/kg as single doseOutpatient: 600 to 800 mg qd in divided dose

to 10 g total, then 200 to 400 mg qd

Hypotension, bradycardia, QT, TdP (rare), GI upset, constipation,

phlebitis (IV)

Intravenous/oral 5 to 7 mg/kg over 30 to 60 min, then 1.2 to 1.8 g qd continuous IV or in divided oral doses

until 10 g total, then 200 to 400 mg qd maintenance

Dofetilide Oral Creatinine Clearance Dose (mL/min) (mcg BID)

>6040 to 6020 to 40

<20

500250125

Contraindicated

QT, TdP; adjust dose for renal function, body size, and age

Recommended Doses of Drugs Effective for Pharmacologic Cardioversion of AF

aDrugs are listed alphabetically. bDosages given in the table may differ from those recommended by the manufacturers. Fuster et al. J Am Coll Cardiol. 2006;48:854-906.

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Druga

Route of Administration Dosageb Potential Adverse Effects

Flecainide Oral 200 to 300 mgc Hypotension, atrial flutter with high ventricular rate

Intravenous 1.5 to 3.0 mg/kg over10 to 20 minc

Ibutilide Intravenous 1 mg over 10 min;repeat 1 mg prn

QT, TdP;

Propafenone Oral 600 mg Hypotension, atrial flutter with high ventricular rate

Intravenous 1.5 to 2.0 mg/kg over10 to 20 minc

Quinidined Oral 0.75 to 1.5 g in divided doses over 6 to 12 h, usually with a rate-

slowing drug

QT, TdP, GI upset, hypotension

Recommended Doses of Drugs Effective for Pharmacologic Cardioversion of AF (cont’d)

aDrugs are listed alphabetically. bDosages given in the table may differ from those recommended by the manufacturers. cInsufficient data are available on which to base specific recommendations for the use of one loading regimen over another for patients with ischemic heart disease or impaired left ventricular function, and these drugs should be used cautiously or not at all in such patients. dThe use of quinidine loading to achieve pharmacologic conversion of AF is controversial, and safer methods are available with the alternative agents listed in the table. Quinidine should be used with caution.

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Pooled Results for the Efficacy and Adverse Effects of Drugs Used in Acute Conversion of AF

aControl indicates placebo, calcium channel blockers, -blockers, or digoxin.McNamara et al. Ann Intern Med. 2003;139:1018-1033.

Sotalol (3) >.2 0-2

Disopyramide (1) .10 Not reported

Quinidine (3) .02 0-12

Amiodarone (15) <.01 0

Propafenone (14) <.01 0-2

Dofetilide (6) <.01 1-12

Flecainide (5) <.01 0-2

Ibutilide (4) <.01 0-9Strong (# trials)

Moderate (# trials)

Inconclusive (# trials)

Level of EvidenceDrug

Odds Ratio of Conversion Compared With Control

(95% CI)a

Range of Sustained Ventricular Arrhythmia

in All Trials ReportingSide Effects P Value

903025201510501

%

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Pharmacologic Management of Patients With Recurrent Paroxysmal Atrial Fibrillation : Sinus Rhythm Maintenance

Recurrent Paroxysmal AFRecurrent Paroxysmal AFRecurrent Paroxysmal AFRecurrent Paroxysmal AF

Minimal orMinimal orno symptomsno symptoms

Minimal orMinimal orno symptomsno symptoms

AnticoagulationAnticoagulationand rate controland rate control

as neededas needed


as neededas needed

DisablingDisablingsymptoms in AFsymptoms in AF

DisablingDisablingsymptoms in AFsymptoms in AF


as neededas needed


as neededas needed

AAD therapyAAD therapyAAD therapyAAD therapyNo drug forNo drug for

prevention of AFprevention of AFNo drug forNo drug for

prevention of AFprevention of AF

AF ablation if AAD AF ablation if AAD treatment failstreatment fails

AF ablation if AAD AF ablation if AAD treatment failstreatment fails


www.HRSonline.org

55

Indications for Use of Antiarrhythmic Therapy for SR Maintenance

• First treat all precipitating or reversible causes• However, many factors, such as age, hypertension, HF, and enlarged LA, are not reversible

• Success of SR maintenance can include infrequent, well-tolerated episodes of AF

• Risk factors for recurrence of AF• Frequent AF (>1 episode per month)

• Female, underlying heart disease

• 4-year recurrence

• Hypertension, age >55 years, AF duration >3 months

• General risks• LA enlargement, rheumatic heart disease, HF


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56

Indications for Use of Antiarrhythmic Therapy for SR Maintenance

• Short-term use• In AF >3 months, short-term therapy after cardioversion may be useful

• Should be started before cardioversion (but after adequate length of anticoagulation)

• Can be used for approximately 1 month

• Long-term use• Best utilized in patients with recurrent paroxysmal AF in whom rhythm control is preferred

• eg, patients with significant symptoms during AF

Fuster et al. Fuster et al. J Am Coll CardiolJ Am Coll Cardiol. 2006;48:854-906.. 2006;48:854-906.

www.HRSonline.org

57

Determining Choice of Antiarrhythmic Agent for SR Maintenance

• Guidelines contain an algorithm for choosing therapy to maintain SR•Choices include antiarrhythmic agents and nonpharmacologic therapy (ablation)

• Algorithm is safety-based with clinical trial evidence of efficacy

• Choices are dependent on patient characteristics

• Classifying patients into appropriate categories is critical for management approach


www.HRSonline.org

58Fuster et al. Fuster et al. J Am Coll CardiolJ Am Coll Cardiol. 2006;48:854-906.. 2006;48:854-906.

Maintenance of Sinus RhythmMaintenance of Sinus RhythmMaintenance of Sinus RhythmMaintenance of Sinus Rhythm

No (or minimal)heart disease


FlecainidePropafenone

Sotalol


Sotalol

AmiodaroneDofetilide


CatheterablationCatheterablation

HypertensionHypertension

SubstantialLVH

SubstantialLVH

NoNo YesYes


Sotalol


SotalolAmiodaroneAmiodarone









DofetilideSotalol

DofetilideSotalol

Coronary artery disease


HeartfailureHeartfailure

AmiodaroneAmiodarone

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59





Sotalol


Sotalol





SubstantialLVH

SubstantialLVH

NoNo YesYes


Sotalol











DofetilideSotalol

DofetilideSotalol






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60

Special Considerations for Patients With HF

• Particularly prone to proarrhythmic effects of antiarrhythmic drugs–Myocardial vulnerability

–Electrolyte imbalance

–Drug interactions

–Renal dysfunction

• Clinical trial evidence for safety with amiodaroneand dofetilide

• Utilize -blocker and ACE inhibitor (or ARB) therapyas indicated for HF or LV dysfunction

• Flecainide and propafenone should be avoided


www.HRSonline.org

61





Sotalol


Sotalol





SubstantialLVH

SubstantialLVH

NoNo YesYes


Sotalol











DofetilideSotalol

DofetilideSotalol






www.HRSonline.org

62

Special Considerations for Patients With Coronary Disease

• Beta blockers can be used, but data are not convincing for SR maintenance

• Sotalol, amiodarone, and dofetilide have neutraleffects on mortality

• Sotalol preferred as monotherapy because of -blocking activity and fewer extracardiac side effects

• Flecainide and propafenone should not be used in these patients because of increased mortalitya

aIncreased mortality seen in CAST studies with flecainide and extrapolation to all class IC agents.Fuster et al. J Am Coll Cardiol. 2006;48:854-906.

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63





Sotalol


Sotalol





SubstantialLVH

SubstantialLVH

NoNo YesYes


Sotalol











DofetilideSotalol

DofetilideSotalol






www.HRSonline.org

64

Special Considerations for Patients With Hypertension

• Hypertension is the most prevalent and modifiable risk factor for AF

• Increased risk of torsades de pointes because of early ventricular after-depolarizations in hypertensive heart disease

• In absence of ischemia or significant LVH, propafenone or flecainide are reasonable choices

• Amiodarone first line in patients with LVH

• In patients with substantial hypertensive heart disease, flecainide and propafenone should be avoided


www.HRSonline.org

65





Sotalol


Sotalol





SubstantialLVH

SubstantialLVH

NoNo YesYes


Sotalol











DofetilideSotalol

DofetilideSotalol






www.HRSonline.org

66

No or Minimal Heart Disease

• Patients with no obvious evidence of structural heart disease

• Normal ECG and ventricular structure and function by echocardiogram; negative stress test (if indicated)

• Flecainide, propafenone, and sotalol have demonstrated efficacy with fewer noncardiac side effects and minimal rates of proarrhythmia in this patient category


www.HRSonline.org

67

Initiation of Antiarrhythmic Drug Therapy

• Ensure normal electrolyte status

• Initiate AV node blockade prior to use of antiarrhythmic agent without substantial AV-node–blocking activity

• Initiate therapy with lower dose and appropriate up-titration as needed and after evaluating drug effects on ECG parameters

• Ensure appropriate anticoagulation prior to starting antiarrhythmic drug therapy


www.HRSonline.org

68

Lafuente-Lafuente et al. Arch Intern Med. 2006;166:719-728.

AF Recurrence

Odds Ratio (95% CI)

Class IA

11,322 patients; 44 trials

Summary of Antiarrhythmic Trials for SR Maintenance

Class IC

(Class II) Metoprolol

Class III:

Amiodarone

Sotalol

0.10 1 10Odds Ratio (95% CI)

Disopyramide vs other Class I drugs

Flecainide vs propafenone

Class I drugs

Sotalol

Sotalol vs class I except quinidine

0.10 1 10

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69

Pritchett et al. Am J Cardiol. 2002;92:941-946; Meinerz et al. Am J Cardiol. 2002;90:1300-1306.

RAFT (n=523)RAFT (n=523)

AF recurrence at 1 year (%)

ERAFT 325 mg BIDERAFT 425 mg BID

RAFT 225 mg BIDRAFT 325 mg BIDRAFT 425 mg BID

0 0.25 0.5 0.75 1

Propafenone better

New Formulations of AADsPropafenone RAFT and ERAFT Studies

ERAFT (n=293)ERAFT (n=293)

Pro

po

rtio

n F

ree

of

Eve

nts

0 50 100 150 200 250 3000

0.2

0.4

0.6

0.8

1

Days

PlaceboPropafenone 225 BIDPropafenone 325 BIDPropafenone 425 BID

P 425 BID vs placebo: OR, 0.604 (95% CI, 0.433-0.843) P=.002

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70

Sotalol vs Amiodarone SAFE-T

Singh et al. N Engl J Med. 2005;352:1861-1872.

1.01.0

0.90.9

0.80.8

0.70.7

0.60.6

0.50.5

0.40.4

0.30.3

0.20.2

0.10.1

SotalolSotalol

PlaceboPlacebo

Amiodarone809/487

DaysDays

Fre

e F

rom

AF

Rec

urr

ence

(O

T/I

TT

)F

ree

Fro

m A

F R

ecu

rren

ce (

OT

/IT

T)

Sotalol 209/74

Placebo 13/6

300300 1000100090090080080070070060060050050040040020020010010000

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71

Typical Doses of Drugs Used to Maintain Sinus Rhythm in Patients With AF

Drug Daily Potential Adverse Effects

Amiodarone 100 to 400 mg Photosensitivity, pulmonary toxicity, polyneuropathy, GI upset, bradycardia, TdP (rare), hepatic toxicity, thyroid dysfunction, eye complications

Disopyramide 400 to 750 mg TdP, HF, glaucoma, urinary retention, dry mouth

Dofetilide 500 to 1000 mcg TdP

Flecainide 200 to 300 mg VT, HF, conversion to atrial flutter with rapid conduction through AV node

Propafenone 450 to 900 mg VT, HF, conversion to atrial flutter with rapid conduction through AV node

Sotalol 160 to 320 mg TdP, HF, bradycardia, exacerbation of chronic obstructive or bronchospastic lung disease

Fuster et al. Am Coll Cardiol. 2006;48:854-906.

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72

New AAD Development

• Beta blockers with Class I or III effects

• Amiodarone congeners

• Atrial-selective antiarrhythmic drugs– IKur- , Ito and IKACh- blocker– Atrial-selective Na channel blocker– 5-HT4 receptor antagonist

• Stretch-activated channel blockers

• ACEI/ARB

• NCX (Na/Ca exchanger) inhibitor

• Anti-inflammatories (statins)

• Gap junction conduction facilitation

www.HRSonline.org

73

Selective Atrial Ion Channel Blockade

Agent Mechanism of Action

MPS IKur

JTV 519 IKACh, IKr

S1185, S9947, S2091 IKur

AVE 0118 IKur, Ito, IKACh

RS100302 (piboserod) 5-HT4 receptor

Vernakalant IKur, Ito, INa, IKACh

Wijffels et al. J Cardiovasc Electrophysiol. 2003;14(9 suppl):S40-S4; Camm et al. Heart Rhythm. 2004;1:244-246.

www.HRSonline.org

74

Drugs That Block Multiple Ion Channels

Agent Mechanism of Action

Dronedarone IKr IKur Ito IKa INa -blocker

Ambasilide IKr IKur IKs

Azimilide IKr IKs

Tedisamil IKr Ito IKATP INa IKur

ATI-2042 IKr IKs B1 ICa Ito INa

AZD 7009 IKr IKur INa

Wijffels et al. J Cardiovasc Electrophysiol. 2003;14(9 suppl):S40-S4; Camm et al. Heart Rhythm. 2004;1:244-246.

www.HRSonline.org

75

Upstream Therapy for Possible Prevention of AF: ACEIs and ARBs

• Empiric observation of benefit in clinical trials

• Decreased atrial pressure, frequency of APBs, fibrosis

• May reduce signal-averaged P-wave duration, number of defibrillation attempts required, number of hospital readmissions for AF

• May have role for primary prevention in patients with hypertension, MI, HF, or diabetes mellitus

• May also reduce the recurrence of AF


www.HRSonline.org

76

Valsartan and AF in VALIANT

Maggioni et al. Am Heart J. 2005;149:548-557.

Est

imat

ed P

rob

abil

ity

of

AF

Est

imat

ed P

rob

abil

ity

of

AF

Months Since RandomizationMonths Since Randomization

0.000.00

0.050.05

0.100.10

0.150.15

00 33 66 99 1212 1515 1818 2121 2424 2727

Log-rank test, Log-rank test, PP=.0001=.0001

ValsartanPlacebo

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77

Candesartan and AF in CHARM

Ducharme et al. Am Heart J. 2006;152:86-92.

0.686 (0.470-1.002)

0.856 (0.617-1.187)

0.894 (0.618-1.295)

0.779 (0.608-0.997), .0472

0.812 (0.662-0.998), .0476

Alternative

Added

Preserved

2 Low EF trials

Overall

P heterogeneity=0.57 Odds Ratio (95% CI), P Value

0.2 0.4 0.6 0.8 1.0 1.2 1.4

Odds Ratio (95% CI)

www.HRSonline.org

78

Kaplan-Meier Plot of Occurrence of Postop AF

Calo et al. J Am Coll Cardiol. 2005;45:1723-1728.

Pat

ien

ts F

ree

of

AF

(%

)P

atie

nts

Fre

e o

f A

F (

%)

Days After SurgeryDays After Surgery

00 11 22 33 44 55 66 77 88 99 1010 1111 1212 1313 1414 1515 1616 1717 18185050

6060

7070

8080

9090

100100

Control GroupControl Group

Log-rank, Log-rank, PP=.009=.009

PUFAs GroupPUFAs Group

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79

Ablation

Catheter-basedSecond-line therapy in most patient categories

• Especially in patients who cannot tolerate antiarrhythmics

• In rare instances, may be first-line therapy

Success rates vary depending on underlying disease, experience of operators, and definitions of success but are ~75% in select groups of patients

Presence of LA thrombus is contraindication

SurgicalGenerally MAZE procedure, utilized in patients already undergoing cardiac procedure


www.HRSonline.org

80

Indications for Catheter AF Ablation

• Symptomatic AF refractory or intolerant to at least one Class I or III antiarrhythmic medication

• In rare clinical situations, it may be appropriate as first-line therapy

• Selected symptomatic patients with heart failure and/or reduced ejection fraction

• Presence of a left atrial thrombus is contraindication to catheter ablation of AF


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81

Who Should Be Referred for Ablation?

• Patients who have been adequately evaluated for AF etiology and underlying diseases

• Highly symptomatic patients in whom one or more antiarrhythmic agents have failed

• Patients with understanding of efficacy and risks of ablation

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82

Patient Selection for Ablation

More Optimal Patient Less Optimal Patient

Variable

Symptoms Highly symptomatic Minimally symptomatic

Class I and III drugs failed 1 0

AF type Paroxysmal Long-standing persistant

Age Younger (<70 years) Older (70 years)

LA size Smaller (<5.0 cm) Larger (5.0 cm)

Ejection fraction Normal Reduced

Congestive heart failure No Yes

Other cardiac disease No Yes

Pulmonary disease No Yes

Sleep apnea No Yes

Obesity No Yes

Prior stroke/TIA No Yes

Courtesy of Hugh Calkins, MD.

www.HRSonline.org

83

Controlled Trials of AF Ablation Patients Free of AF (% at 1 Year)

87

56

75

8679

86

0

10

20

30

40

50

60

70

80

90

100

RAAFT CACAF A4 APAF Milan/NR PABA CHF

Ablation Control

Courtesy of Jeremy N. Ruskin, MD, Massachusetts General Hospital.

Per

cen

t

www.HRSonline.org

84

Pooled Studies: Observational and RCTs Patients Free of AF at 1-2 Years (%)

23%

77%

0

20

40

60

80

100

Free of AF Recurrent AF

10%

76%

0

20

40

60

80

100

Ablation Control

RCT: N=517; 4 StudiesOBS: N=1965; 8 Studies

Courtesy of Jeremy N. Ruskin, MD, Massachusetts General Hospital.

Per

cen

t

Per

cen

t

www.HRSonline.org

85

Worldwide Survey on Ablation Procedures for AF (1995-2002)

• 8745 patients (age range 16-86 years); 90 ablation centers

• Overall success rate: 76%–52% without AADs

–24% with AADs

• Major complication rate: 6%

• 27% required >1 procedure

• Follow-up: 11.6 7.7 months

Cappato et al. Circulation. 2005;111:1100-1105.

www.HRSonline.org

86

Success Rates With Ablation Worldwide Survey

0

10

20

30

40

50

60

70

80

90

100

0-3 4-6 7-9 10-12 13-18 19-24 >24

Success Without AADs Success With AADs Overall Success


Rat

es (

%)

Rat

es (

%)

Range of Follow-up (months)Range of Follow-up (months)

www.HRSonline.org

87

Worldwide Survey on Ablation for AF Major Complications


0

0.5

1

1.5

2

Death Tamponade Stroke TIA PVstenosis

Infection,pneumo/Hemo-thorax,

diaphragmparalysis

Femoralpseudo-

aneurysm,AV

fistula

Valvedamage,

Aodissection

Per

cen

t

www.HRSonline.org

88

AF-Free Survival Ablation vs Pharmacologic Therapy

Pappone et al. J Am Coll Cardiol. 2003;42:185-197.

No. at riskNo. at riskAblationAblation 589589 507507 479479 379379 282282 217217 135135MedicalMedical 582582 456456 354354 277277 207207 141141 9797

AF

-Fre

e A

F-F

ree

Su

rviv

al P

rob

abil

ity

(%)

Su

rviv

al P

rob

abil

ity

(%)

100100

8080

6060

4040

2020

0000 180180 360360 540540 720720 900900 10801080

Days of Follow-upDays of Follow-up

Ablation GroupAblation Group

Medical GroupMedical Group

www.HRSonline.org

89

Freedom From AF Following Pulmonary Vein Isolation Normal vs Impaired LV Function

Chen et al. J Am Coll Cardiol. 2004;43:1004-1009.

3030 6060 9090 120 150150 180180 210210 240240 270 300300 330 360360 390390 4204204040

5050

6060

7070

8080

9090

100100

Cu

mu

lati

ve A

F-F

ree

Su

rviv

alC

um

ula

tive

AF

-Fre

e S

urv

ival

Follow-up Time (days)Follow-up Time (days)

Impaired LV Function (n=94)Impaired LV Function (n=94)

Normal LV Function (n=283)Normal LV Function (n=283)

P=.03

www.HRSonline.org

90

RAAFT Outcomes at 1 Year

No significant difference in Severe, moderate, or mild pulmonary vein stenosisa

Bradycardia

Bleeding

Thromboembolic eventsb

Significant difference Hospitalization

• AAD (54%) vs PVI (9%)

• P<.001

Symptomatic AF recurrence

• AAD (63%) vs PVI (13%)

• P<.001 Su

rviv

al F

ree

From

Atr

ial F

ibril

latio

nSu

rviv

al F

ree

From

Atr

ial F

ibril

latio

n

1.01.0

0.90.9

0.80.8

0.70.7

0.60.6

0.50.5

0.40.4

0.30.3

0.20.2

0.10.1

0.00.00.00.0 100100 200200 300300

Follow-up (days)Follow-up (days)

Antiarrhythmic Antiarrhythmic Drug GroupDrug Group

PVI GroupPVI Group

www.HRSonline.org

91

CACAF Study of Ablation in Drug-Refractory AF

Stabile et al. Eur Heart J. 2006;27:216-221.

Atrial Arrhythmia–Free Survival Curves After the Blanking Period

MonthsMonths

Per

cen

t S

urv

ival

Per

cen

t S

urv

ival

100100

8080

6060

4040

2020

00

00 11 22 33 44 55 66 77 88 99 1010 1111 1212

PP<.001<.001

Ablation Group (n=68)Ablation Group (n=68)

Control Group (n=69)Control Group (n=69)

www.HRSonline.org

92

A4 Study Results

Jaïs et al. Presented at: Heart Rhythm Society 2006 Annual Scientific Sessions;May 17-20, 2006; Boston, MA.

0

10

20

30

40

50

60

70

80 Ablation Group (n=53) AAD Group (n=59)

Per

cen

t

Free of Arrhythmia Recurrenceat 1 Year (%)

Discontinued OralAnticoagulation (%)

www.HRSonline.org

93

A4 Study Results

Kaplan-Meier Plots for Time to AF Recurrence

75%

1.0

7%

Pro

bab

ilit

y o

f N

o

AF

Rec

urr

ence

0.9

0.80.7

0.6

0.50.4

0.30.2

0.10.0

0 100 500

Follow-up Days

200 300 400

P<.0001 (log-rank test)

Ablation

Antiarrhythmic Drug

Jaïs et al. Presented at: Heart Rhythm Society 2006 Annual Scientific Sessions; May 17-20, 2006; Boston, MA.

www.HRSonline.org

94

Limitations of Current Ablation Data

• Few current trials are prospective

• Single-center results not necessarily reflective of general results

• Ablation patients frequently also receive AADs

• Therapy crossovers

www.HRSonline.org

95

CABANA Trial

Packer. Presented at 2005 Scientific Sessions of the American Heart Association. November 13-16; Dallas, TX.

Recent-onset AFEligible for ablation or drug therapy 65 years old or<65 years with 1 risk factor for CAD or stroke

Primary Ablation(technique at

operator discretion)

Primary Ablation(technique at

operator discretion)

Drug Therapy(rate or rhythm control[at operator discretion]with anticoagulation)

Drug Therapy(rate or rhythm control[at operator discretion]with anticoagulation)

ContinuedAnticoagulation

ContinuedAnticoagulation

DiscontinuedAnticoagulation

DiscontinuedAnticoagulation

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96

Improvement in LV Function and Dimensions After Ablation in Patients With CHF

Plotted values are means SD. P values, which are for the comparison with baseline data, were determined with the use of Fisher’s least-significant-difference test. The numbers of patients included at each time point were as follows: 0 month, 58; 1 month, 55;3 months, 48; 6 months, 40; 12 months, 34.Hsu et al. N Engl J Med. 2004;351:2373-2383.

70

60

50

40

30

025

35

45

55

65

LV E

ject

ion

Frac

tion

(%)

0 1 3 6 12Month

7570

6055

04550

65

LV E

nd-D

iast

olic

D

iam

eter

(mm

)

0 1 3 6 12Month

P<.001P<.001P<.001P<.001

P<.001P<.001P<.001P<.001

P=.001P=.001P<.001P<.001P=.001P=.02P=.03P=.001

LV E

nd-S

ysto

lic

Dia

met

er (m

m) 55

03035404550

0 1 3 6 12Month

40

25

20

0

35

LV F

ract

iona

l Sh

orte

ning

(%)

0 1 3 6 12Month

30

15

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97

Estimated Outcomes and Risks of AF Ablation

Courtesy of Hugh Calkins, MD.

Success Single Procedure Multiple Procedure

Optimal patient 60%-80% 80%-90%

Less optimal patient 50%-70% 70%-80%

Poor candidate <40% 40%-60%

Major Complication Rates 2%-12%

Left atrial flutter 2%-5%

Vascular access related 1%-5%

Cardiac tamponade 0.5%-3%

Stroke 0.5%-2%

PV stenosis <1%

Phrenic nerve injury <0.5%

Esophageal perforations <0.2%

Mitral valve entrapment <0.1%

Acute coronary occlusion <0.1%

Death <0.1%

www.HRSonline.org

98

Common Lesions Performed in AF Ablation


LSPV

LIPV

RSPV

IVC

RIPV

SVC

LSPV

LIPV

RSPV

IVC

RIPV

SVC

LSPV

LIPV

RSPV

IVC

RIPV

SVC

LSPV

LIPV

RSPV

IVC

RIPV

SVC

www.HRSonline.org

99

Ablation Techniques

• Ablation strategies that target PVs and/or PV antrum are cornerstones for most AF ablation procedures

• If PVs are targeted, complete electrical isolation should be goal

• For surgical PV isolation, entrance and/or exit block should be demonstrated

• Careful identification of PV ostia is mandatory to avoid ablation within PVs

• If focal trigger is identified outside PV at time of AF ablation procedure, it should be targeted if possible


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100

Postablation Management

• LMWH or IV heparin as bridge to systemic anticoagulation

• Warfarin for all patients for 2 months

• Use of warfarin >2 months following ablation based on patient’s risk factors for stroke and not presence or type of AF

• Discontinuation of warfarin therapy postablation generally not recommended for CHADS2 score 2


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101


Blanking period

• Blanking period 3 months after ablation when reporting outcomes

Definition of success

• Freedom from AF/flutter/tachycardia without antiarrhythmic therapy is 1o end point

• Freedom from AF at various points following ablation may be better marker of true benefit; consider as 2o end point

• Atrial flutter and other atrial tachyarrhythmias=treatment failures

• An episode of AF/flutter/tachycardia with duration of 30 seconds detected by monitoring considered recurrence


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102


Minimal monitoring

• Follow-up minimum of 3 months following ablation procedure; then every 6 months for 2 years

• Obtain event monitor to screen for recurrrent AF/flutter/tachycardia in patients with palpitations during follow-up

• AF/flutter/tachycardia episode present if documented by ECG lasting 30 seconds

• 24-hour Holter monitoring is acceptable minimal monitoring strategy for patients in clinical trials and recommended at 3-6 month intervals for 1-2 years


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103


Repeat procedures

• Repeat procedures should be delayed for at least 3 months following initial ablation if patient’s symptoms can be controlled with medical therapy

Complication reporting

• Major complications are defined as those that result in permanent injury or death, require intervention for treatment, or prolong or require hospitalization


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104

Take-Home Points

• Heart rate control at rest and with exertion is critical foreither AF strategy

• Rate vs rhythm approach should be guided by many factors, most importantly, symptoms and appropriate application of clinical trials

• Guidelines contain algorithms on how to choose method for SR maintenance

• Certain antiarrhythmics are appropriate for select groups of patients

• Ablation is an important option in SR maintenance

• Appropriate patient categorization is critical for management

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