af update october 2016 -...
TRANSCRIPT
AF update October 2016
Dr Edward Duncan MRCP PhD
Consultant Cardiologist & Electrophysiologist
Bristol Heart Institute
and Bristol Heart Rhythm Centre
Aspirin in Stroke
Prevention 18.6.14
Key message:
What’s wrong with aspirin?
• 64% RR with warfarin (tough act to follow)
– (could be greater…many strokes occurred when INR < 2)
• 8 RCTs compared aspirin vs placebo (n=4876)
– 7 showed a non-significant stroke reduction
• 9 RCTs compared aspirin with warfarin; all showed inferiority
• “It’s safer than warfarin in the elderly, falls etc…”
• Birmingham AF Treatment of the Aged (BAFTA)
– Warfarin superior to aspirin (52%) in all strokes (fatal, disabling, ischaemic
or haemorrhagic)
– No difference in bleeding risk
• Warfarin vs Aspirin for Stroke Prevention in Octogenerians (WASPO)
– Warfarin superior to aspirin
– Significantly higher bleeding risk with aspirin (33% vs 6%)
What’s wrong with aspirin?
Management of typical atrial flutter
• Thromboembolic risk
• Ventricular rate control
• DC cardioversion
• Anti-arrhythmic drugs
• Catheter ablation
Management of typical atrial flutter
• Thromboembolic risk
• Ventricular rate control
• DC cardioversion
• Anti-arrhythmic drugs
• CATHETER ABLATION
Management of the patient with AF
(my thought processes)
1) Thromboprophylaxis
2) Symptom control
3) LV protection
Decreasing
importance
• Rate vs Rhythm control
– If rate control:
• Betablocker, Diltiazem, Digoxin
• Pace and ablate
– If rhythm control:
• Oral anti-arrhythmic therapy
– Bisoprolol, Flecainide, Sotalol, Amiodarone
• (DCCV)
• Catheter ablation
Symptom control in AF
• All typical flutter patients
• Symptomatic patients with AF who fail 1 AAD
• Paroxysmal (PAF) > persistent (PsAF)
• PsAF < 1 years duration
or PsAF who maintain SR post DCCV
Who to refer for catheter ablation?
Ablation versus AAD
Wilber, D. J., C. Pappone, et al. (2010). "Comparison of antiarrhythmic drug therapy and radiofrequency catheter
ablation in patients with paroxysmal atrial fibrillation: a randomized controlled trial." Jama 303(4): 333-40.
• 75 year old man
• PMH Gout, HTN, CKD, PCI 2010
• BP check
• Irregular pulse
• ECG – AF 75bpm
• Mx?
• CHADSVASc
• Symptoms
• Echo and routine bloods
Scenario
• 60 year old woman
• Temporal arteritis, Ca Breast
• Oncology F/up OPA
• ECG – 80bpm, typical flutter
• Mx?
• CHADSVASc
• Symptoms
• Echo and routine bloods
• Refer for Ablation
Scenario
• 80 year old man
• tAVR and grafts 2011
• SOB
• New AF 120bpm
• Mx?
• CHADSVASc?
• Symptoms?
• Rate control. Which drugs?
• Echo
• Refer?
• DCCV?
Scenario
• 4/12 post DCCV
• SR
• Vast improvement
• Meds review:
• Warfarin
• Bisoprolol
• ARB
• Statin
• What changes?
The same patient
• 53 year old man
• EtOH 35 units per week
• 3x A+E with AF
• Acutely DCCV or iv flecainide
• GP f/up for palpitations
• Mx?
• CHADSVASc
• Symptoms
• Echo and routine bloods
• Medical therapy?
• ?refer
Scenario
• Arrhythmia hx
• PMH and Drug hx
• CHADSVASc score
• Symptoms
• Echo
• Bloods
The AF/flutter consultation
Arrhythmia Subtype 1st line Rx 2nd line Rx Other Rx
SVT AVNRT
AVRT
AT
Atrial flutter
AF PAF
PsAF
VT/VF Structural Heart dis
Arrhythmia Subtype 1st line Rx 2nd line Rx Other Rx
SVT AVNRT Ablation
AVRT
AT
Atrial flutter
AF PAF
PsAF
VT/VF Structural Heart dis
Arrhythmia Subtype 1st line Rx 2nd line Rx Other Rx
SVT AVNRT Ablation Ablation
AVRT
AT
Atrial flutter
AF PAF
PsAF
VT/VF Structural Heart dis
Arrhythmia Subtype 1st line Rx 2nd line Rx Other Rx
SVT AVNRT Ablation Ablation Conservative
AVRT
AT
Atrial flutter
AF PAF
PsAF
VT/VF Structural Heart dis
Arrhythmia Subtype 1st line Rx 2nd line Rx Other Rx
SVT AVNRT Ablation Ablation Conservative
AVRT Ablation Ablation Conservative
AT Ablation Ablation Conservative
Atrial flutter
AF PAF
PsAF
VT/VF Structural Heart dis
Arrhythmia Subtype 1st line Rx 2nd line Rx Other Rx
SVT AVNRT Ablation Ablation Conservative
AVRT Ablation Ablation Conservative
AT Ablation Ablation Conservative
Atrial flutter Ablation
AF PAF
PsAF
VT/VF Structural Heart dis
Arrhythmia Subtype 1st line Rx 2nd line Rx Other Rx
SVT AVNRT Ablation Ablation Conservative
AVRT Ablation Ablation Conservative
AT Ablation Ablation Conservative
Atrial flutter Ablation Ablation Conservative
AF PAF
PsAF
VT/VF Structural Heart dis
Arrhythmia Subtype 1st line Rx 2nd line Rx Other Rx
SVT AVNRT Ablation Ablation Conservative
AVRT Ablation Ablation Conservative
AT Ablation Ablation Conservative
Atrial flutter Ablation Ablation Conservative
AF PAF Medical
PsAF
VT/VF Structural Heart dis
Arrhythmia Subtype 1st line Rx 2nd line Rx Other Rx
SVT AVNRT Ablation Ablation Conservative
AVRT Ablation Ablation Conservative
AT Ablation Ablation Conservative
Atrial flutter Ablation Ablation Conservative
AF PAF Medical Ablation
PsAF
VT/VF Structural Heart dis
Arrhythmia Subtype 1st line Rx 2nd line Rx Other Rx
SVT AVNRT Ablation Ablation Conservative
AVRT Ablation Ablation Conservative
AT Ablation Ablation Conservative
Atrial flutter Ablation Ablation Conservative
AF PAF Medical Ablation PPM + node
PsAF
VT/VF Structural Heart dis
Arrhythmia Subtype 1st line Rx 2nd line Rx Other Rx
SVT AVNRT Ablation Ablation Conservative
AVRT Ablation Ablation Conservative
AT Ablation Ablation Conservative
Atrial flutter Ablation Ablation Conservative
AF PAF Medical Ablation PPM + node
PsAF Medical
+/- DCCV
VT/VF Structural Heart dis
Arrhythmia Subtype 1st line Rx 2nd line Rx Other Rx
SVT AVNRT Ablation Ablation Conservative
AVRT Ablation Ablation Conservative
AT Ablation Ablation Conservative
Atrial flutter Ablation Ablation Conservative
AF PAF Medical Ablation PPM + node
PsAF Medical
+/- DCCV Ablation
VT/VF Structural Heart dis
Arrhythmia Subtype 1st line Rx 2nd line Rx Other Rx
SVT AVNRT Ablation Ablation Conservative
AVRT Ablation Ablation Conservative
AT Ablation Ablation Conservative
Atrial flutter Ablation Ablation Conservative
AF PAF Medical Ablation PPM + node
PsAF Medical
+/- DCCV Ablation PPM + node
VT/VF Structural Heart dis
Arrhythmia Subtype 1st line Rx 2nd line Rx Other Rx
SVT AVNRT Ablation Ablation Conservative
AVRT Ablation Ablation Conservative
AT Ablation Ablation Conservative
Atrial flutter Ablation Ablation Conservative
AF PAF Medical Ablation PPM + node
PsAF Medical
+/- DCCV Ablation PPM + node
VT/VF Structural Heart dis
Medical +/- ICD
Arrhythmia Subtype 1st line Rx 2nd line Rx Other Rx
SVT AVNRT Ablation Ablation Conservative
AVRT Ablation Ablation Conservative
AT Ablation Ablation Conservative
Atrial flutter Ablation Ablation Conservative
AF PAF Medical Ablation PPM + node
PsAF Medical
+/- DCCV Ablation PPM + node
VT/VF Structural Heart dis
Medical +/- ICD
Ablation Nil