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August 20, 2013

Contemporary

Treatment Optionsfor SymptomaticPatientsFor patients with symptomatic AF who feelbetter in sinus rhythm, radiofrequency ablationoffers an opportunity for cure. While successrates are highest in patients with paroxysmalatrial fibrillation, many centers, including TheAl-Sabah Arrhythmia Institute, have physicianswith excellent cure rates even in patients withlong-standing persistent atrial fibrillation. Atour institution, more than half of all patientsreferred have persistent AF. Despite the upfrontrisk of complications with interventional

therapy, the longterm proarrhythmic effects,(including that of life threatening ventriculartachyarrhythmias) of antiarrhythmic drugtherapy are well known.1 Thus, whileantiarrhythmic drug therapy simply decreases

the burden of AF, ablation offers a realopportunity for cure; randomized clinical trialssupport this finding2 and explain how ablation

has become an important option for thesymptomatic patient (figure 1). In addition,studies have shown that patients3,4 treatedwith catheter ablation for AF have fewerhospitalizations as compared to thoserandomized to drug therapy, thus improvingquality of life and decreasing outpatient aswell as inpatient visits.5

It is critical to note that ablation is indicatedonly in patients with symptomatic atrialfibrillation6 given the current data andrecommendations from the Heart RhythmSociety. While patients at relatively low risk forthromboembolism (CHADS 2 score of 1) canbe considered for cessation of anticoagulationafter a successful ablation for AF, the guidelines

do not recommend discontinuation ofanticoagulation for those at high risk for stroke.Other non-pharmacological therapies offeralternative options to lifelong anticoagulation.

W W W . S T L U K E S C A R D I

The NumbersKeep Rising:What it Means tothe IndividualMore than two million Americans have beendiagnosed with atrial fibrillation. While somepresent with symptoms such as palpitations

and rapid heart action, others present moreinsidiouslydyspnea with exertion, decreasedexercise tolerance, and fatigue, all of which areoften ascribed to as getting older. Manyothers, however, have no symptoms, and arediagnosed during a routine examination. Basedon the presence or absence of symptoms, thepatient and physician must ultimately decidewhether to pursue a rate or rhythm controlstrategy.

Whether one has symptoms or not, eachpatient must be risk stratified for stroke.Ultimately, the mainstay of therapy for thetreatment of atrial fibrillation has beenmedications. Antiarrhythmic drugs (flecainide,propafenone, sotalol, dofetilide, amiodarione,

etc.) to maintain sinus rhythm andatrioventricular nodal blocking agents (betablockers and calcium channel blockers) tocontrol the rapid ventricular rates thataccompany AF are commonly prescribed. Inaddition, medications for anticoagulation(warfarin, dabigatran, rivaroxaban, apixaban)are used to lower the risk of stroke.

Recent adavances in electrophysiology,however, have opened up an entirely newparadigm in treating this disease. Non-pharmacological therapies have rapidlydeveloped and allow physicians to offerpatients percutaneous interventions that mayobviate the need for antiarrhythmic drugs oranticoagulation.

Each IndividualRequires anIndividualizedApproachThe appropriate treatment strategy for patientswith AF varies from patient to patient anddepends on the presence or absence of

symptoms and the risk of thromboembolism.For those whose quality of life is significantlyimpacted by atrial fibrillation, options exist tobest suit the wants and needs of each patient.Most importantly, a satisfactory decision canbe made only when a thorough discussion ofevery reasonable treatment modality has beendiscussed. Ultimately, it is the patient whowill decide how to proceed with the under-standing of the risks and benefits of eachpathway available.

Any Atrial Arrhythmia

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Save the Date

August 20, 2013

CME: Update onAtrial Fibrillation

October 17, 2013, 5:30 pmLincoln Center

References:

1Corley SD, Epstein AE, DiMarco JP, et al. Relationships between

sinus rhythm, treatment, and survival in the Atrial Fibrillation

Fol- low-Up Investigation of Rhythm Management (AFFIRM)

Study. Circulation. Mar 30 2004;109(12):1509 1513.

2Jais P, Cauchemez B, Macle L, et al. Catheter ablation versus

antiarrhythmic drugs for atrial fibrillation: the A4 study.

Circulation. Dec 9 2008;118(24):2498 2505.

3Wilber DJ, Pappone C, Neuzil P, et al. Comparison ofantiarrhyth- mic drug therapy and radiofrequency catheter

ablation in patients with paroxysmal atrial fibrillation: a

randomized controlled trial. JAMA. Jan 27 2010;303(4):333340.

4Wazni OM, Marrouche NF, Martin DO, et al. Radiofrequency

ablation vs antiarrhythmic drugs as first-line treatment of

symptom- atic atrial fibrillation: a randomized trial. JAMA. Jun 1

2005; 293(21):2634 2640.

5Piccini JP, Lopes RD, Kong MH, Hasselblad V, Jackson K, and Al-Khatib SM. Pulmonary Vein Isolation for the Maintenance of

Sinus Rhythm in Patients With Atrial Fibrillationf: A Meta-Analysis

of Randomized, Controlled Trials. Circ Arrhythm Electrophysiol.

2009 Dec;2(6):626-33.

6Calkins H, Kuck KH, Cappato R, Brugada J, Camm J, et al. 2012

HRS/EHRA/ECAS Expert Consensus Statement on Catheter and

Surgical Ablation of Atrial Fibrillation: Recommendations forPatient Selection, Procedural Techniques, Patient Management

and Follow-up, Definitions, Endpoints, and Research Trial Design.

Heart Rhythm, 2012.

Figure 1: Freedom from any atrial arrhythmia in pat

undergone catheter ablation is significantly reduced

to those r andomized to anti-arrhythmic drug (AAD)

From: Comparison of antiarrhythmic drug therapy a

frequency catheter ablation in patients with paroxy

fibrillation: a randomized controlled trial. Wilber DJ

Neuzil P, De Paola A, Marchlinski F, Natale A, Macle

Calkins H, Hall B, Reddy V, Augello G, Reynolds MRLiu CY, Berry SM, Berry DA; ThermoCool AF Trial In

JAMA. 2010 Jan 27;303(4):333-40.

Figure 2: (a) and (b) Intracardiac echo (ICE) images

placed in the left atrium and pulmonary veins. ICE

added significantly to the safety and outcomes wit

(c) Illustration showing the position of catheters as

in (a) and (b) above

1.00

0.80

0.60

0.40

0.20

0.00

Catheter ablation

Antiarrhythmicdrug therapy

HR, 0.29; 95% CI, 0.18-0.45;

log-rank P,.001

Figure 1

7/29/2019 Arrhythmia News: September 2013

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NONPROFIT

ORGANIZATION

U.S. POSTAGE

PAID

PERMIT NO. 8048

NEW YORK, NY

W W W . S T L U K E S C A R D I

The Continuum Cardiovascular Centers of New Yorkis pleased to announce the appointments of:

Andrea Natale, MDExecutive Director of the Al-Sabah Arrhythmia Institute

Conor Barrett, MDDirector of the Al-Sabah Arrhythmia Institute

Stephan Danik, MDDirector, Electrophysiology Lab

The Al-Sabah Arrhythmia Institute is a state-of-the-art facility that offers the most advanced andsophisticated arrhythmia care. Funded by HisHighness Sheikh Sabah Al-Ahmad Al-Jaber Al-Sabah,the Amir of Kuwait, the Institute has the capacity toserve more than 3,000 patients annually and is one

of the only facilities focused specifically on arrhythmiatreatments in the New York City metro area.

St. Lukes Hospital

1111 Amsterdam Avenue

New York, NY 10025

This Issue: Atrial Fibrillation: Does Your Patient Have to Live with I t?

VOL.1, ISSUE 1SEPTEMBER 2013

The Al-SabahArrhythmia Institute

Andrea Natale, MDExecutive Director

Conor D. Barrett, MDDirector

Stephan B. Danik, MDDirector, ElectrophysiologyLab

Robert K. Altman, MD

Francesco Santoni, MD

Emad Aziz, DO

Walter Pierce, MD

Erdal Gursoy, MD

Sam Hanon, MD

Patrick W. Lam, MD

Pretty Chawla, MD

St. Luke's Hospital1111 Amsterdam Avenue5 BabcockNew York, NY 10025

Roosevelt HospitalBrodsky Building425 West 59th Street,Suite 9CNew York, NY 10019

Phone:212.523.2400

Atrial Fibrillation: Does YPatient Have to Live withDoes the increasing burden of atrial fibrillation (AF) mthose affected will need to take more medications aadjust their lifestyles accordingly? Not necessarily.

A diagnosis of AF even 10 years ago would havecondemned one to a whole cocktail of medications ftreatment. For many patients, the addition of three t

four more pills per day can mean the tipping point wit becomes difficult to remember to take the right doat the right time. In addition, does the fear of an epiin symptomatic patients with paroxysmal atrial fibrillarequire that patients curtail their activities or avoid trand stay close to home?

Such was the case that atrial fibrillation was a diseasthat, once diagnosed, would usually mean lifelongmedications to help manage the debilitating symptoand the risk of stroke. Unfortunately, there was no cand while anticoagulation was extremely effective atreducing the risk of stroke, antiarrhythmic drug thercould at best decrease the burden of the disease in twith severe symptoms who would eventually have tolearn to live with it.

L to R: Stephan Danik, MD; Andrea Natale, MD and Conor Barrett, MD