management of atrial fibrillation
DESCRIPTION
MANAGEMENT OF ATRIAL FIBRILLATION. VINOD G V. Definitions. Paroxysmal AF - self-terminating, usually within 48 h, may continue for up to 7 days. Persistent AF - when an AF episode either lasts longer than 7 days or requires termination by cardioversion . - PowerPoint PPT PresentationTRANSCRIPT
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MANAGEMENT OF ATRIAL FIBRILLATION
VINOD G V
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Definitions
• Paroxysmal AF - self-terminating, usually within 48 h, may continue for up to 7 days.
• Persistent AF - when an AF episode either lasts longer than 7 days or requires termination by cardioversion.
Long-standing persistent AF has lasted for ≥1 year when it is decided to adopt a rhythm control strategy.
Permanent AF-DC version failed or not attempted• Recurrent AF-has had 2 or more episodes
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“lone AF” • generally applies to young individuals under
60 y of age without clinical or echocardiographic evidence of cardiopulmonary disease including hypertension .
• have a favorable prognosis with respect to thromboembolism and mortality.
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Haemodynamics
• Loss of atrial contraction• A rapid ventricular rate• An irregular ventricular rhythm
• Loss of mechanical AV synchrony affects ventricular filling esp. when left ventricle has reduced compliance.
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• 3 objectives
Rate control
prevention of thromboembolism
correction of the rhythm disturbance,
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Type and duration of AF
Severity and type of symptoms
Associated cardiovascular disease
Patient Age
Associated medical conditions
Pharmacological and nonpharmacological therapeutic options.
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• Rapid ventricular rate produce symptoms Tachycardia related cardiomyopathy
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Rate control
• Strict rate control: Resting HR -60-80 Moderate exercise 90-110• Lenient HR Resting HR <100
RACE II (RAte Control Efficacy in permanent atrial fibrillation) trial did not identify a benefit of stringent rate control over lenient rate control therapy in 614 patients
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Primary Outcomes
Cardiac deathCHFStrokeSystemic embolismMajor bleedSyncopeSust VTCardiac arrestLife threat compl of antiarrhythmicPacemaker
Secondary Outcomes
Symptoms
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• Beta-Blockers useful in the presence of high adrenergic tone or symptomatic myocardial ischaemia
• Non dihydropyridine CCB-Diltiazem,verapamil • Digoxin-effective at rest ,not during exercise
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Rhythm control
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Theoretical Benefit of Rhythm Control
• Improved hemodynamics• Relief of symptoms• Improved exercise tolerance• Reduced risk of stroke• Avoidance of anticoagulants
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Rhythm control
• Pharmacological
• Non pharmacological Cardioversion Catheter Ablation
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Cardioversion in AF
• Pharmacological
• Electrical cardioversion
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DC Cardioversion
• Delivery of an electric shock synchronised with the intrinsic activity of heart by sensing the R wave
• Successful cardioversion depends on Duration of AF Current density delivered to atrial myocardium
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Joglar JA et alAm J Cardio 2000
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Mittal S et al Ciculation 2000
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Elhendy A et al Am J Cardio 2002
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Pharmacological cardioversion
• Simple • Less efficaious• More effective in AF <7 day duration• Problems of drug toxicity
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• AF lasting <1 wk – cardioversion -using oral flecainide, propafenone, dofetilide, and intravenous ibutilide.
• For longer duration- iv dofetilide( also amiodarone and ibutilide may be useful)
• Single oral dose of propafenone or flecainide – in recent onset AF (pill in the pocket)
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2 strategies• Oral warfarin with a therapeutic INR (2–3) for 3 to 4
weeks before cardioversion followed by continued warfarin thereafter
• Transesophageal echocardiography (TEE) and heparin immediately before cardioversion followed by oral warfarin thereafter.
• Left atria – stunning effect. So anticoagulation is to be continued for 4 wks
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AF upto 7 days
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AF >7 days
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Pharmacological Rhytm control
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Major Trials Comparing Rhythm Strategy and Rate Strategy
Major trials include:– AFFIRM (Atrial Fibrillation Follow-Up Investigation of Rhythm Management )– RACE (rate control versus electrical cardioversion)– PIAF (pharmacological intervention in AF)– AF-CHF
Major overall findings: – Rhythm-control strategy was not superior to rate-control strategy in terms of
morbidity/mortality– Appropriate choice of therapy should be based on each patient’s symptoms and
disease– rate control, prevention of thromboembolism, and correction of the rhythm
disturbance - these strategies are not mutually exclusive
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AFFIRM : 5 Year Outcomes
Survival Rhythm control Rate control
1yr 96 96
3yr 87 89
5yr 76 79
NO DIFFERENCE:Death, major bleed ,disabling stroke,cardiac arrest
Sinus rhythm maintained in only 63% of rhythm control group
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AFFIRM Trial
• No survival advantage to rhythm control.• Rhythm control patients were more likely to be
hospitilized with adverse drug effects.• Both groups had similar stroke risk (1% per yr)
– Majority of strokes when warfarin stopped or INR subtherapeutic– Warfarin required long term even if sinus rhythm restored
• Torsades, bradycardic arrest more common with rhythm control.
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• Attempts at restoration of sinus rhythm not always successful– AFFIRM Trial: only 63% of “rhythm control” group were in sinus
rhythm– Antiarrhythmics used to maintain sinus rhythm associated with a
25-50% annual failure rate.
• Long term anticoagulation not mandated in the “rhythm control” group– Those in afib at risk for stroke
• Medications used to maintain sinus rhythm risk of proarrhythmia and other toxicity
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Vernakalant
• Acts preferentially in atria• Blocking several ion channels• Prolongation of atrial refractoriness• Rate dependent slowing of atrial conduction• Little impact on ventricular repolarization
Pharmacological cardioversion of AF <7 days or <3days for patients after cardiac surgery
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AVRO• Double-blind,active-controlLed -i.v. amiodarone• N=232 Vernakalant n = 116, Amiodarone n = 116• Hypertension(71.6%) ischaemic heart disease(22.4%)
myocardial infarction (8.2%) heartfailure(19.8%)(NYHA I- 45.7%, NYHA54.3%) valvular heart disease, 6.9%
• AF 3–48 h (median 17.7 h) Time to conversion 11m• Conversion to SR- 51.7% vs. 5.2% P <0.0001• Reduction in symptoms at 2 h reported by 53.4%
patients in the vernakalant groupvs. 32.8% in the Amiodarone group P = 0.0012
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“Pill in the Pocket” strategy
• Preferred in– Paroxysmal AF with no structural heart disease– Self administration of a single oral dose of drug
shortly after the start of palpitations– Decrease hospital visitsPropafenone 450-600mgFlecainide 200-300mg
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Anti-arrhythmic drugs for maintaining sinus rhythm
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Selection of specific agent depends on underlying cardiac disease
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CATHETER ABLATION IN AF
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Factors
• Factors that trigger
• Factors that perpetuate
• Triggering foci of rapidly firing cells within the sleeve of atrial myocytes extending into the pulmonary veins - shown to be the underlying mechanism of most paroxysmal AF
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When to consider ablation?
• Antiarrhythmic therapy ineffective
• Antiarrhythmic therapy not tolerated
• Symptomatic afib
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• The stage of atrial disease ( AF type, LA size, AF history)
• The presence and severity of underlying cardiovascular disease
• Potential treatment alternatives (antiarrhythmic drugs, rate control)
• Patient preference
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• Anatomic ablation
• Electrogram guided ablation
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Anatomic Carto Map of Lett atrium ablation points
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Ablation may be a first strategy
• Patient very symptomatic in AF and refuses antiarrhythmic drug therapy
• Young patient whose only effective antiarrhythmic drug is amiodarone
• Patient with significant bradycardia for whom antiarrhythmic drug therapy will require pacemaker
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Results
• Difficult to interpret– Success rate
• Optimal patient: – single procedure 60 - 80%– Multiple procedures 80 – 90%– Poor patient (eg 3 years persistent afib, sig enlarged LA
– Best success with paroxysmal and healthy heart– Least success with chronic and diseased left atrium– May recur despite initial success– May recur without symptoms
• Ultimate goal: Rhythm control without toxic antiarrhythmics
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• Complication rate 1-5%– Tamponade – atrial perforation– TIA, stroke– Major bleed– Creation of atrial flutter (up to 8%)– Vascular access complications– Pulmonary vein stenosis (lower incidence than initial)– Aorto-esophageal fistula– Fatal 1/1000
• Lengthy procedure– 4-5 hours
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Risk factors for recurrence of afib
Long-term persistent afibValvular heart diseaseDilated cardiomyopathy
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Anti Thrombotic therapy
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Risk stratification
• CHADS2 – Congestive heart failure - 1pt– Hypertension - 1pt– Age > 75 - 1 pt– Diabetes - 1pt– Stroke or TIA - 2 pts
– 0 points – low risk (1.2-3.0 strokes per 100 patient years)– 1point– moderate risk (2.8-4.0 strokes per 100 patient years)– > 2 points – high risk (5.9-18.2 strokes per 100 patient years)
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CHA2DS2-VASC
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Anticoagulation strategy
• CHADS2 score 0 No anti thrombotic therapy• CHADS2 score 1 Aspirin 75-325 mg daily Oral anti coagulation• CHADS2 score 2 Oral anti coagulation
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Anti thrombotic therapy
• VKA eg: warfarin
• Antiplatelets eg aspirin,clopidogrel
• Newer oral anti coagulants Direct thrombin inhibitor-Dabigatran Fa Xa inhibitors-Apixaban,Rivaroxaban
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Warfarin
• Effective• Reversible• Inexpensive
• Slow onset of action• Regular monitoring• Food interraction• Medication interraction• Difficult titration-regular dose adjustments
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Aspirin
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Clopidogrel + Aspirin ?
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• Aspirin:
stroke 3.4% per year
major bleed 1.27% per year
• Aspirin + clopidogrel:
stroke 2.4% per year
major bleed 2.0% per year
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New anticoagulants
• Short half life – less bleeding
• Lack of need for routine monitoring
• Generally safer than warfarin– No antidote
• Cost of medication– Overall cost of care
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Apixaban (Aristotle trial)
• Twice daily: 5mg BD• Less hemorrhagic stroke than warfarin• Similar reduction in ischemic stroke• Less bleeding than warfarin• Lower overall mortality• No routine lab testing• No reversal
– Half life 8-15 hours
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Dabigatran(RELY trial)
• Dabigatran 110 mg twice daily– Equal to warfarin in stroke prevention
• Warfarin 1.69%/yr – dabigatran (110mg) 1.53%/yr– Less bleeding than warfarin
• Warfarin 3.36%/year – dabigatran (110mg) 2.71%/yr
• Dabigatran 150 mg twice daily– More effective than warfarin in stroke prevention
• Dabigatran (150mg) 1.11%/yr– Equivalent bleeding to warfarin
less hemorrhagic stroke than warfarin
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Rivaroxaban (Rocket AF trial)
• Once daily: 20 mg• Less hemorrhagic stroke than warfarin• Similar reduction in ischemic stroke• Less bleeding than warfarin• No routine lab testing• No reversal
– Half life 5-9 hours
• Discontinuation : increased stroke
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• CHADS2 score includes all except1.TIA2.Age > 60 yrs3.DM4.Congestive heart failure
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• 55 yr old man with AF , no h/o HTN,DM ,no structural heart disease TRUE regarding antithrombotic therapy
1.Aspirin 150 mg OD2.Warfarin 2mg 3.Dabigatran 150 mg BD4.No antithrombotic therapy needed
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• 30 yr old patient presented to emergency department with 2hr h/o palpitation ,ECG showing wide complex irregular tachycardia rate 200/min preferred method of treatment
1.IV Verapamil2.IV Diltiazem3.IV Digoxin4.IV Procainamide
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• Drug used in “pill in the pocket strategy”1.Sotalol2.Propafenone3.Ibutalide4.procainamide
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• True about Dabigatran except1.RE-LY trial evaluated dabigatran2.Two doses were evaluated in RE-LY trial3.Rate of haemorragic stroke more compared to
warfarin4.Dose adjustment needed in CKD
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• CHA2DS2 VASc score includes all except1.Age 65-74 yrs2.Male sex3.Atherosclerotic plaque in aorta4.HTN
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• Drug prefered for maintainance of sinus rhythm in structurally abnormal heart is
1.Sotalol2.Betablockers3.Amiodarone4.Ibutalide
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Rivaroxaban true except1.Rivaroxaban better than warfarin in reducing
stroke in AF 2.20 mg twice daily3.Less haemorrhage than warfarin4.Evaluated in ROCKET AF trial
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• VERNAKALANT all are true except1.Acts preferentially in atria2.Causes significant QT prolongation3.Used in post operative AF conversion4.Contraindicated in heart failure
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• Apixaban TRUE EXCEPT1.Direct thrombin inhibitor2.Evaluated in ARISTOTLE trial3.Cause less haemorrhage than warfarin4.Non inferior to warfarin in stroke prevention