Cardiovascular Update 2014 Workshop
Atrial Fibrillation – Stroke, Bleeding and why is it so confusing ?
Dr Ken Butcher Dr Micha Dorsch
Högertrafikomläggningen
Patient 1: VA• 84 year old lady
• Long history of hypertension currently well controlled on Perindopril, Bisoprolol, Chlorthalidone and Amlodipine
• Type 2 diabetes on Metformin (HBA1c: 7.4)
• Dyslipidaemia on Rosuvastatin (LDL 1.6)
• Routine office visit with family physician: no symptoms, but pulse irregularily irregular
What next ?
VA: EKG
What other tests?
Other tests
• Thyroid function test• Haemoglobin• ? Echo• ?? Ischemia work up• ??? Other tests really required
Anticoagulation?
Anticoagulation ?• CHADS2 = 3, equivalent to annual stroke
risk of 5.9%
• CHA2DS2-VASC = 5, equivalent to annual stroke risk of 15.3% (2012 ESC guideline update)
• HAS-BLED = 2, equivalent to 1.88 major bleeds in 100 patient years
All calculations performed on: www.mdcalc.comMajor bleed: bleeding requiring transfusion or hospitalisation or Hb drop greater 2g/L
Figure 1
Canadian Journal of Cardiology 2014 30, 1114-1130DOI: (10.1016/j.cjca.2014.08.001) Copyright © 2014 Canadian Cardiovascular Society Terms and Conditions
2014-11-30
Rate or rhythm control ?
Rate vs Rhythm control: AFFIRM
AFFIRM investigators: A comparison of rate control and rhythm control in patients with Atrial fibrillation. NEJM 2002; 347: 1825-33
What is rate control ?
Van Gelder et al. Lenient vs. strict rate control in patients with atrial fibrillation. NEJM 2010;362: 1363-73
Rate control: Strict vs lenient
Not so confusing at all, is it?• Started on Coumadin, opted for rate
control
• No further cardiac testing
• 12 months follow-up– Pt remains asymptomatic– Changed from coumadin to rivaroxaban by
family physician (difficult to control INR)
Patient 2: JA• 56 year old lady• Paroxysmal atrial fibrillation since 2001• Very symptomatic with one episode every 3-6
months• 18 admissions requiring DCCV, 5 Cardiologists• Intolerant of Sotalol, Dronedarone, Atenolol,
Warfarin, Rivaroxaban and Dabigatran• On Diltiazem 90 mg bid and ASA (sometimes)• 19. admission RAH ER Jan 2014
Admission 19, Cardiologist Nr 6
• Woke up at 05.00 with palpitations and dizziness
• Called EMS at 07.00
• EMS: A fib, rate 160, BP: 86/45
What next ?
Acute Management
• Attempted DCCVx3 by EMS, remains in Afib
• Procainamide i.v.: worsening hypotension
• CCU admission: spontaneous cardioversion
A fib – possible longterm strategies
• Continuous antiarrhythmic drug therapy
• Pill in the pocket approach
• Invasive management: pulmonary vein isolation
Pharmacotherapy - options
• Sotalol
• Dronedarone
• Propafenone/Fleccainide
• Amiodarone
Anticoagulation ?• CHADS2 = 0, equivalent to annual stroke
risk of 1.9%
• CHA2DS2-VASC = 1, equivalent to annual stroke risk of 2% (2012 ESC guideline update)
• HAS-BLED = 0, equivalent to 1.13 major bleeds in 100 patient years
All calculations performed on: www.mdcalc.com
JA: further management
• Changed Diltiazem bid to Tiazac XC 240 mg daily
• Started on Apixaban
• Propafenone 600mg (pill in the pocket approach)
OA review: Sep 2014• D/C Apixaban after 2 weeks for side effects and
restarted ASA
• Tolerates Tiazac XC and takes it regularly
• 2 episodes of paroxysmal A fib since, terminated by Propafenone
• Offered her workup for pulmonary vein isolation: currently not interested
Pill in the pocket approach
• 268 patient with paroxysmal atrial fibrillation and structurally normal heart
• Treated in ER with Propafenone or Fleccainide as per site investigator`s preference
• 210 treated successfully and without side effects were given pill in the pocket
• 84% success rate, no serious side effects
Alboni et al.: Out-patient management of recent onset atrial fibrillation with the pill in the pocket approach. NEJM2004; 351:2384-91.
A Fib management
Anticoagulant/Antiplatelettherapies
CHADS2/CHA2DS2-VASC SCORE
HAS BLED
Patient preference
Rhythm vs Rate control
Symptoms
Probability of maintaining SR
Patient preference
Treatable aetiological factors
Structural heart disease
Sleep disordered breathing
Hyperthyroidism…
A Fib: My approach
Figure 2
Canadian Journal of Cardiology 2014 30, 1114-1130DOI: (10.1016/j.cjca.2014.08.001) Copyright © 2014 Canadian Cardiovascular Society Terms and Conditions
2014-11-30
Figure 3
Canadian Journal of Cardiology 2014 30, 1114-1130DOI: (10.1016/j.cjca.2014.08.001) Copyright © 2014 Canadian Cardiovascular Society Terms and Conditions
2014-11-30
Atrial Fibrillation – Stroke, Bleeding and why is it so confusing ?